WtVEftSfTY  OF  CALIFORNIA 
">U«WIA  COUEGE  OF  MEDICO 

I  W?ARY 

AUG  1  5  1972 
'RVINE,  CAUFORNIA  9266* 


/ 


THE  DISEASES  OF  THE  EAR 


PRACTICAL  TREATISE 


DISEASES  OF  THE  EAR 


INCLUDING 


A    SKETCH    OF   AURAL    ANATOMY  AND 
PHYSIOLOGY 


D.  B.  ST.  JOHN    ROOSA,   M.D.,  LL.D. 

Professor  of  Diseases  of  the  Eye  and  Ear  in  the  New  York  Post-Graduate  Medical  School 
and  President  of  the  Faculty  ;  Surgeon  to  the  Manhattan  Eye  and  Ear  Hospital ; 
Consulting  Surgeon  to  the  Brooklyn  Eye  and  Ear  Hospital ;  formerly  Pro- 
fessor of  Ophthalmology  in  the  University  of  the  City  of  New  York^ 
and  of  Diseases  of  the  Eye  and  Ear  in  the  University  of  Ver- 
mont;  formerly  President  of  the  Medical  Society 
of  the  State  of  New  York,  etc.,  etc. 


SEVENTH    REVISED    EDITION 


NEW    YORK 
WILLIAM   WOOD    &    COMPANY 

1891 


COPTRIGHT,   1891,   BY 

WILLIAM  WOOD  &  COMPANY. 


TROW  DIHICTORY 

i  AND  BOOKBINDING  ( 

N1W  YORK 


TO  MY  FEIEND 

Ualbot  Els,  fl&.B. 

IN   REMEMBRANCE   OF   OUR   YEARS   OP    INTIMATE   PROFESSIONAL  AND   SOCIAL 

RELATIONS,    THIS    BOOK    IS   AFFECTIONATELY 

DEDICATED 


PREFATORY   NOTE   TO   THE    SEVENTH   EDITION. 


IN  this  edition,  certain  changes  and  additions  have  been 
made,  which  it  is  hoped  will  increase  the  value  of  the  book. 
Such  additions  will  be  especially  observed,  in  the  discussion  of 
the  relation  of  diseases  of  the  nose  and  throat  to  the  ear,  the 
value  of  operations  upon  the  drum-head  and  ossicles,  as  well  as 
in  the  history  and  practice  of  operations  upon  the  mastoid. 
Minor  changes  have  also  been  made  in  many  parts  of  the  book, 
and  a  new  and  more  complete  index  has  been  made  by  Dr.  Frank 
N.  Lewis.  The  last  edition  was  translated  into  German  by  Dr. 
Ludwig  Weiss,  and  published  in  Berlin  by  August  Hirschwald. 
The  author  sincerely  hopes  that  his  book  may  continue  to  find 
readers,  not  only  among  students  of  medicine,  but  among  practi- 
tioners as  well,  for,  although  otology  has  made  great  strides  in 
the  last  decade,  it  still  lags  behind  many  departments  of  our 
science  and  art,  in  the  estimation  and  knowledge  of  the  pro- 
fession at  large.  Even  among  specialists,  who  are  devoted  to 
otology  and  fields  not  remote  from  it,  a  wider  knowledge  of 
what  has  been  done  for  diseases  of  the  ear,  would  sometimes  be 
of  service  in  lessening  the  quantity  of  literature  upon  well  dis- 
cussed themes.  I  therefore  hope  that  this  book  may  not  be 
anywhere  considered  as  an  elementary  work,  suitable  only  for 
undergraduates  in  medicine.  In  many  parts  it  consists  rather 
of  a  series  of  monographs  intended  for  specialists  as  well  as  for 
general  practitioners. 

NEW  YORK,  August  22,  1891. 


PREFACE  TO  THE  SIXTH  EDITION. 


IT  is  now  eleven  years  since  the  first  edition  of  this  work  was 
published.  The  manner  in  which  it  has  been  received  by  the 
profession  of  this  country  and  of  Great  Britain  and  Ireland,  has 
been  a  source  of  great  gratification  to  me.  I  offer  my  hearty 
thanks  to  my  brethren  for  having  given  my  labors  in  otology 
such  a  kind  appreciation.  In  revising  this  book,  while  perhaps 
no  page  has  escaped  alteration,  and  many  pages  have  been 
added,  pains  have  been  taken  to  preserve  the  original  plan. 
It  was  written  for  three  classes  of  readers.  First,  it  is  intended 
to  be  a  means  by  which  advanced  medical  students  may  acquire 
a  knowledge  of  the  diseases  and  anatomy  of  the  ear.  .  Second,  it 
is  designed  for  general  practitioners,  to  whom  it  may  be  a  guide 
for  the  diagnosis  and  treatment  of  cases  actually  in  hand.  Third, 
I  also  hope,  that  professional  men  who  interest  themselves 
largely  or  exclusively  in  otology,  may  in  the  future  as  in  the 
past,  find  in  it  something  of  interest  and  profit  to  them. 

The  larger  part  of  the  work  is  essentially  a  digest  of  my  own 
experience  in  the  treatment  of  diseases  of  the  ear,  now  ex- 
tending over  more  than  twelve  thousand  cases  for  which  I  have 
had  the  personal  responsibility.  The  nomenclature  of  this 
book  has  been  accepted  quite  generally  in  the  profession,  and 
some  of  the  views  which  were  set  forth  for  the  first  time  in  the 
first  edition,  have  been  recognized  as  true,  and  have  taken  their 
place  in  the  great  structure  of  human  knowledge. 

In  this  edition,  it  will  be  found  that  I  have  endeavored  to 


PREFACE  TO   THE   SIXTH   EDITION. 

make  deductions  from  my  clinical  experience  in  certain  novel 
directions.  Time  will  eventually  establish  the  truth,  or  expose 
the  incorrectness  of  the  conclusions  which  I  have  drawn  from 
my  cases.  If  any  of  them  are  wrong,  the  facts  at  least  will  re- 
main, I  trust,  a  substantial  contribution  to  a  department  of 
medicine  to  which  I  have  given  some  of  the  best  years  of  my  life. 

I  wish  to  express  my  thanks  to  my  valued  friend,  Dr. 
Charles  E.  Hackley,  for  his  aid  and  advice  in  correcting  the 
proofs,  also  to  Dr.  J.  B.  Emerson  for  the  preparation  of  the  in- 
dex, and  much  other  assistance. 

Many  of  the  anatomical  illustrations  were  prepared  expressly 
for  this  edition,  and  most  of  these  are  from  the  museum  of  my 
distinguished  colleague,  Professor  William  Darling.  While  en- 
gaged upon  this  work,  Dr.  John  L.  Yandervoort  has  extended 
to  me  great  courtesy  in  his  official  position  as  Librarian  of  the 
New  York  Hospital.  Many  of  the  engravings  of  instruments 
were  furnished  me  by  Messrs.  John  Reynders  &  Co. 

NEW  YORK,  November  1,  1884. 


PREFACE  TO  THE  FIRST  EDITION. 


THIS  work  is  intended  to  be  a  guide  to  those  who  wish  to  treat 
the  diseases  of  the  ear.  The  portion  that  is  devoted  to  a  de- 
scription of  these  diseases,  and  the  means  for  their  relief  and 
cure,  is  founded  upon  my  own  experience  in  the  observation  and 
treatment  of  more  than  thirty-eight  hundred  cases,  in  public 
and  private  practice.  I  have,  however,  taken  pains  to  give  the  ex- 
perience of  other  practitioners,  both  at  home  and  abroad.  I  have 
endeavored  not  only  to  give  a  comprehensive  digest  of  the  most 
recent  European  researches,  but  also  to  present,  with  entire  im- 
partiality, the  views  and  experiences  of  American  practitioners 
and  writers,  so  far  as  the  plan  of  a  practical  treatise  like  this 
would  allow.  To  give  a  complete  account  of  all  that  has  been 
written  on  otology  has  not,  however,  been  my  aim. 

Considerable  space  has  been  given  to  illustrative  cases,  with  a 
view  of  showing  the  actual  symptoms  of  aural  diseases  and  the 
results  of  treatment.  I  have  also  added  historical  sketches  upon 
all  points  of  practice  that  are  new  or  still  under  discussion,  in 
order  that  the  successive  steps  by  which  our  present  position  has 
been  reached  might  be  distinctly  traced,  believing  that  thereby 
the  practitioner  will  often  be  saved  needless  labor  in  re-investi- 
gating and  re-experimenting.  The  nomenclature  contained  in 
this  treatise  is  that  which  I  have  found,  after  some  years  of  ex- 
perience in  lecturing  upon  diseases  of  the  ear,  most  readily 
grasped  by  the  student,  and  is,  I  believe,  founded  upon  the 
real  nature  of  the  diseases. 

The  anatomical  portion  of  the  volume  has  been  compiled  from 
the  most  recent  authorities.  The  text-book  of  Professor  J. 
Henle,  of  Gottingen,  a  work  which  has  not  been  translated  into 


X  PREFACE  TO  THE  FIRST   EDITION. 

English,  has  been  made  the  general  basis  of  the  descriptions  of  the 
various  parts  of  the  ear,  and  of  the  arrangement  of  the  subject. 

In  the  preface  to  a  translation  of  "  Von  Troltsch  on  the  Ear," 
published  a  little  more  than  nine  years  since,  the  translator  had 
so  little  faith  in  a  general  professional  interest  in  the  diagnosis 
and  treatment  of  diseases  of  the  ear,  that  he  quoted  a  proverb 
to  indicate  that  an  ordinary  human  life  would  not  suffice  to  see 
the  fruit  of  the  tree  then  being  planted,  in  presenting  to  the 
English-speaking  profession  a  work  which  has  done  much  for 
the  progress  of  otology.1 

In  view,  however,  of  the  active  and  permanent  interest  in  this 
subject,  which  has  shown  itself  in  the  formation  of  societies,  the 
establishment  of  journals,  improvements  in  methods  of  practice, 
and  a  general  appreciation  of  diseases  of  the  ear,  the  author  can 
but  felicitate  himself  that  even  in  a  short  life  he  has  seen  some 
fruit  of  a  tree,  which,  although  he  did  not  plant,  he  at  least  as- 
sisted in  cultivating. 

The  practice  of  otology  in  this  country  was,  a  few  years 
since,  almost  exclusively  confined  to  charlatans  ;  but  it  is  now 
cultivated  by  a  class  of  men  who  are  the  equals  of  any  in  the 
profession.  Ten  years  ago,  in  most  parts  of  the  country,  those 
who  wished  advice  upon  a  disease  of  the  ear  were  forced  to  seek 
aid  outside  of  the  profession.  At  the  present  time,  there  can 
be  found  those  in  the  large  cities  who  are  constantly  and  suc- 
cessfully treating  aural  diseases  ;  and  all  over  the  land  the  old 
and  familiar  advice,  "Not  to  meddle  with  the  ear,"  is  growing 
far  less  frequent.  The  day  will  soon  arrive — if  indeed  it  be  not 
already  upon  us — when  otology  will  take  equal  rank  with 
ophthalmology,  to  which  department  it  has  so  long  been  a 
mere  appendage,  and  when  some  knowledge  of  the  diseases  and 
treatment  of  the  ear  will  be  required  of  every  practitioner. 

I  have  been  assisted  in  various  ways,  in  the  preparation  of 
this  work,  by  many  who  may  rest  assured  that  I  have  not  been 
unmindful  of  their  labors  because  their  names  are  not  here 
mentioned  ;  but  to  Dr.  Charles  E.  Rider,  of  Rochester,  for  assist- 
ance in  compiling  the  anatomy  of  the  middle  ear,  and  to  Dr. 
George  M.  Beard,  for  critical  suggestions  in  the  literary  execu- 
tion of  the  work,  of  a  very  valuable  character,  I  am  much  in- 


1  "  Arbores  seret  diligens  agricola  quarum  adspiciet  baccam  ipse  nunquam." 


PREFACE   TO   THE  FIEST   EDITION".  xi 

debted,  and  to  both  of  these  gentlemen  I  desire  to  present  my 
cordial  acknowledgments. 

It  is  believed  that  in  the  foot-notes,  the  various  authorities 
whom  I  have  consulted  have  been  given  proper  credit,  and  they 
are  given  in  full  at  the  close  of  the  sketch  of  the  progress  of 
otology,  and  at  the  end  of  each  anatomical  section,  in  order 
that  an  aural  bibliography  of  works  actually  consulted  by  the 
author,  and  accessible  in  this  country,  may  be  furnished  to 
any  who  may  desire  to  pursue  any  special  subjects  further  than 
would  be  fitting  the  limits  of  a  text-book. 

Most  of  the  engravings  were  made  by  Messrs.  J.  A.  Cough- 
Ian  &  Co.  Those  of  instruments  were  furnished  by  Messrs. 
Shepard  &  Dudley,  Otto  &  Reynders,  and  George  Tiemann  & 
Co.,  of  this  city. 

The  chromo-lithographs  were  drawn  by  Dr.  H.  P.  Quincy, 
of  Boston,  from  cases  loaned  me  by  Drs.  Clarence  J.  Blake  and 
Henry  L.  Shaw,  Surgeons  to  the  Massachusetts  Charitable  Eye 
and  Ear  Infirmary.  Without  the  assistance  of  these  gentlemen, 
I  should  have  found  it  very  difficult  to  procure  satisfactory 
representations  of  the  morbid  membrana  tympani.  Dr.  John 
L.  Vandervoort,  Librarian  of  the  New  York  Hospital,  has  ex- 
tended me  many  courtesies  in  giving  me  free  access  to  the 
valuable  library  of  that  institution. 

NEW  YORK,  May  29,  1873. 


CONTENTS. 


CHAPTER  I. 

A  SKETCH  OF  THE  PROGEESS  OP  OTOLOGY  WITH  A  BIBLI- 
OGRAPHY. 

PAGE 

Vastness  of  Otological  Literature. — Apathy  in  regard  to  Diseases  of  the  Ear. — Wilde 
the  Reformer  of  the  Science. — Carl  Gustav  Lincke  and  his  Handbook. — Papy- 
rus Ebers. — Hippocrates  and  his  Knowledge  of  the  Ear. — Alcmaeon  the  Dis- 
coverer of  the  Eustachian  Tube. — Rufus  of  Ephesus. — Aristotle. — Discoveries 
in  the  Time  of  the  Ptolemys. — Galen  and  the  Want  of  Progress  in  his  Time. 
— Achillini  and  Berengario  describe  the  Ossicles. — Vesalius  the  most  accurate 
Anatomist  of  his  Day. — Ingrassia,  Columbo,  and  Eustachius  each  claims  Dis- 
covery of  Stapes. — Fallopius  and  his  Career. — Anatomical  Writings  of  Eusta- 
chius.— First  Monograph  on  Anatomy  of  the  Ear. — Constant  Varolius. — Fab- 
ricius  of  Aquapendente. — Valsalva. — Casserius,  a  Pupil  and  Rival  of  Fabricius. 
— Stenon  describes  Ceruminous  Glands. — Discovery  of  Helicotrema. — Du  Ver- 
ney  and  his  Plates. — Cotugno  and  the  Aqueducts. — Meckel. — Rivinian  Fora- 
men.— Hyrtl  and  Bochdalek  upon  its  Existence. — Ruysch. — Brendel  and 
Zinn. — Scarpa  upon  the  Internal  Ear. — Saunders,  Todd,  and  others. — Monro's 
Claim  to  have  first  traced  the  Nerves  into  the  Cochlea,  Vestibule,  and  Semi- 
circular Canals. — Everard  Home's  Account  of  the  Membrana  Tympani. — 
Soemmering. — Shrapnell. — Thomas  Buchanan  on  the  Importance  of  Cerumen. 
— Wharton  Jones. — Discoveries  of  Toynbee. — Troltsch,  Politzer,  Lucse,  and 
others. — The  Organ  of  Corti  and  its  Discoverer. — Pathological  Anatomy  of  the 
Ear. — Progress  in  Treatment  of  Aural  Disease. — Herodotus  on  Specialists. — 
The  Remedies  suggested  by  Hippocrates. — Celsus. — Archigenes  on  Venesection 
and  Foreign  Bodies. — Galen  on  Noise. — Peculiar  Method  of  removing  Foreign 
Body  from  Ear. — Paulus  ^Sgineta,  his  Classification  and  Operation. — Arabians, 
their  Knowledge  of  Otology. — Paracelsus  burning  Books  of  his  Predecessors.— 
Capivacci  on  Differential  Diagnosis. — Ambroise  Pare  first  uses  a  Syringe  for 
the  Ear. — The  Education  of  Deaf  Mutes. — Old  Method  of  detecting  Inspis- 
sated Cerumen. — Lusitanus  on  cutting  off  Ears  of  Thieves. — Fabricius  of  Hil- 
den. — Thomas  Willis,  his  Observations  on  Hearing  in  a  Noise. — The  Thera- 
peutical Work  of  Valsalva. — Petit  on  Caries  of  the  Mastoid. — The  Discovery 
of  the  Eustachian  Catheter. — Guyot,  Cleland. — Perforation  of  the  Membrana 
Tympani. — Trephining  the  Mastoid. — Sir  Astley  Cooper. — Saunders  on  Perfo- 
ration of  the  Membrana  Tympani. — First  Infirmary  for  Diseases  of  the  Ear. — 
Saissy,  Itard,  Beck. — Sketch  of  Kramer's  Career. — Discovery  of  Artificial 
Membrana  Tympani. — Yearsley. — Wilde  and  his  great  Work  in  Otology. — 
The  Text-books  of  Toynbee,  Troltsch,  Erhard. — Modern  Text-books  and  Jour- 
nals.— Bibliography, 1 


XIV  CONTENTS. 

CHAPTER  II. 
THE  EXAMINATION  OF  AURAL  PATIENTS. 

PAGE 

History. — Power  of  Hearing  Conversation. — Test  Sentences. — Tick  of  a  Watch. — 
Tuning-fork. — Aerial  and  Bone  Conduction. — Malingering. — Angular  Forceps. 
—Specula. — Troltsch's  Otoscope. — Examination  of  Pharynx. — Rhinoscopy. — 
Use  of  Eustachian  Catheter. — Politzer's  Method  and  its  so-called  Modifica- 
tions.— Bougies. — Valsalva's  Method, 44 

CHAPTER  III. 

ANATOMY  AND   PHYSIOLOGY   OF   THE  AURICLE    AND   THE 
EXTERNAL  AUDITORY  CANAL. 

Auricle. — Etymology.— Anatomy  of  Muscles,  Intrinsic  and  External. — Physiology. 
— Blood-vessels. — Nerves. — External  Auditory  Canal. — Anatomy  of  Curva- 
ture.— Ceruminous  Glands. — Hairs  in  Canal. — Auditory  Canal  of  Dog  and  Cat. 
— Relations  of  Canal  to  Parotid  Gland,  Inferior  Maxilla,  Mastoid  Process,  and 
Dura  Mater. — Blood-vessels  and  Nerves, 81 

CHAPTER  IV. 
THE  MALFORMATIONS  AND  DISEASES  OF  THE  AURICLE. 

A  Finely  Formed  Auricle  an  Indication  of  Character. — Malformations. — Super- 
fluous Auricles. — Ely's  operation  for  Prominent  Auricles. — Tumors. — Angio- 
mata.  — Othaematomata. — Perichondritis.  —  Malignant  Growths.  — Syphilitic 
Affections. — Erysipelas. — Effects  of  Gout 97 

CHAPTER  V. 

DIFFUSE  AND  CIRCUMSCRIBED  INFLAMMATION  OF  THE  EXTER- 
NAL AUDITORY  CANAL. 

Comparative  Frequency  of  these  Affections. — Diffuse  Inflammation. — Leeches. — 
Incisions. — Warm  Douche. — Fountain  Syringe. — Fayette  Taylor's  Douche. — 
Method  of  Syringing. — Syringes. — Anodynes. — Desquamative  Inflammation. 
— Furuncles. — Local  and  Constitutional  Treatment. — Calcium  Sulphide. — 
Lowenburg's  Views, 123 

CHAPTER  VI. 

PARASITIC  INFLAMMATION  OF  THE  EXTERNAL  AUDITORY  CANAL 
—SYPHILITIC  ULCERS  AND  CONDYLOMATA— CONTRACTIONS- 
DIPHTHERIA— SARCOMA— CARIES. 

History  of  the  Discovery  of  the  Growth  of  Aspergillus  in  the  External  Auditory 
Canal. — Varieties  of  Vegetable  Fungi  found  in  the  Ear. — Cases. — Syphilitic 
Ulcers  and  Condylomata. — Narrowing  and  Closure  of  the  Canal. — Diphtheritic 
Inflammation. — Sarcoma. — Caries  of  the  Canal, 143 


CONTENTS.  XV 

CHAPTER  VII. 
INSPISSATED  CERUMEN. 

PAOB 

Merely  a  Symptom  of  Aural  Inflammation. — Frequency  of  the  Affection. — Symp- 
toms.— Reported  Cases  of  Damage  to  the  Ear  from  the  Presence  of  Wax,  prob- 
ably not  based  on  Correct  Observation. — Causes. — Treatment. — Cases,  .  .  158 

CHAPTER  VIII. 
FOREIGN  BODIES. 

Exaggeration  of  the  Importance  of  this  Subject. — Statistics. — Insects. — Living  Lar- 
vae.— Fish. — Inanimate  Foreign  Bodies. — Treatment. — Delusions  as  to  Foreign 
Bodies  in  the  Ear. — Foreign  Bodies  in  the  Eustachian  Tube. — Ear  Cough,  .  179 

CHAPTER  IX. 
ANATOMY  AND  PHYSIOLOGY  OF  THE  MIDDLE   EAR. 

Statistics  of  Diseases  of  the  Middle  Ear. — Membrana  Tympani. — ShrapnelFs  Mem- 
brane.— Rivinian  Foramen. — Light  Spot.  — Layers. — Blood-vessels. — Nerves. 
— Lymphatics. — Cavity  of  the  Tympanum. — Scheme  for  Studying  Boundaries 
of  this  Cavity. — Ossicula  Auditus. — Blood-vessels. — Nerves. — Mastoid  Pro- 
cess.— Eustachian  Tube,  Historical  Account  of. — Physiology  of  the  Middle 
Ear, 213 

CHAPTER  X. 
INJURIES   OF  THE   MEMBRANA   TYMPANI. 

Diseases  of  the  Memhrana  Tympani  not  Independent  Affections.  —Vascular,  Nerv- 
ous, and  Lymphatic  Supply,  a  Part  of  that  of  the  Canal  and  Middle  Ear. — 
Drum-head  Subject  to  Injury  by  Explosions,  Blows,  and  so  forth. — Effects  of 
Condensed  Air. — Serious  Injuries  of  the  Head. — Fracture  of  the  Handle  of 
the  Malleus, 2r,9 

CHAPTER   XI. 

ACUTE  CATARRHAL  INFLAMMATION  OF  THE  MIDDLE  EAR. 

Nomenclature. — Statistics. — Symptoms. — Treatment. —  Leeches.  —  Paracentesis. — 
Subacute  Catarrh. — Hemorrhagic  Inflammation  of  the  Middle  Ear. — -Aural 
Hemorrhage  in  Bright's  Disease. — Vascular  Tumors  of  the  Drum-head,  .  .  1!78 

CHAPTER   XII. 

ACUTE  SUPPURATION  OF  THE  MIDDLE  EAR. 

A  Consequence  of  Acute  Catarrh. — Symptoms. — Causes. — Course. — Cases  of  Men- 
ingitis Consecutive  to  Acute  Catarrh  and  Suppuration. — Criticisms  upon  the 
Modern  Antiphlogistic  Treatment. — Neurotic  Cases. — Treatment  and  Cases. — 
Acute  Serous  Inflammation  of  the  Middle  Ear, 30? 


XVi  CONTENTS. 

CHAPTER   XIII. 

CHBONIC   NON-SUPPUBATIVE    INFLAMMATION   OF   THE   MID- 
DLE EAE. 

PAGE 

Frequency  of  this  Disease. — Nomenclature. —Catarrh. — Proliferous  Inflammation. 
— Subjective  Symptoms. — Vertigo. — Tinnitus  Aurium.  — Insanity.  — Subjec- 
tive Symptoms  of  Proliferous  Inflammation. — Objective  Symptoms. — Impair- 
ment of  Hearing. — Changes  in  the  Membrana  Tympani. — Eustachian  Tube. — 
Naso-pharyngeal  Inflammation. — Adenoid  Growths. —Pathology. — Causes,  .  339 

CHAPTER  XIV. 

CHBONIC  NON-SUPPUBATIVE  INFLAMMATION  OF  THE  MIDDLE 

EAB— (Continued). 

Treatment  of  the  Catarrhal  and  Proliferous  Forms. — Constitutional  and  Hygienic 
Applications  to  the  Naso-pharyngeal  Space. — Nasal  Douche. — Cases  of  Acute 
Aural  Disease  caused  by  its  Use. — Gruber's  Method  of  Cleansing  Nares. — Pol- 
itzer's  Method. — Anatomy  of  Nasal  Cavities. — Nebulizers. — Faucial  Catheters. 
— Removal  of  the  Tonsils. — Treatment  through  the  Eustachian  Tube. — Air. 
Steam. — Vapors. — Fluids. — Bougies. — Electricity. — Death  from  Improper 
Use  of  Catheter. — Duration  of  Treatment. — Prognosis, 380 

CHAPTER  XV. 

THE  TBEATMENT  OF  CHBONIC  NON-SUPPUBATIVE  INFLAM- 
MATION— ( Concluded) . 

Operations  upon  and  through  the  Membrana  Tympani. — History  from  1650  until 
our  own  Day. — Sir  Astley  Cooper's  Cases. — Schwartze's  Statistics. — Politzer's 
Eyelet. — Tenotomy  of  Tensor-tympani. — Galvano-cautery. — Division  of  Pos- 
terior Fold. — Front's  Operation. — Hinton's  Removal  of  Accumulations  of  Mu- 
cus.— Abandonment  of  Operations  by  American  Otologists. — Condensed  Air. 
— Exhaustion  of  Air. — Weber-Liel  and  Woakes  on  Paretic  Deafness. — Results 
of  Treatment,  .............  415 

CHAPTER  XVI. 
CHRONIC  SUPPUBATION  OF  THE  MIDDLE  EAB. 

Consequence  of  Acute  Suppuration. — Otorrhcea  an  Improper  Term. — Often  con- 
founded with  Chronic  Inflammation  of  the  Canal. — Relative  Frequency  of  the 
two  Affections. — Symptoms. — Perforations  of  Membrana  Tympani.— Treat- 
ment.— Syringing. — Astringents. — Fluids. — Powders. — Electricity. — Artificial 
Membrana  Tympani. — Cases. — Prognosis, 443 

CHAPTER  XVII. 

THE  CONSEQUENCES  OF  CHBONIC  SUPPUBATION  OF  THE 
MIDDLE  EAB. 

Chronic  Suppuration  and  its  Results  Inevitably  Dangerous  to  the  Health  and  Life 
of  the  Patient. — Refusal  of  Life  Insurance  Companies  to  take  Risks  of  such 
Cases. — Cicatrices  and  Adhesions  in  the  Tympanum. — Polypi. — Exostoses. — 
Mathewson's  Operation  for  their  Removal. — Cases, 473 


CONTENTS.  XVli 

CHAPTER  XVIII. 

THE   CONSEQUENCES   OF   CHEONIC   SUPPURATION   OF  THE 
MIDDLE  EAE—  (Continued). 

Diseases  of  the  Mastoid  Process. — Periostitis. — Caries  and  Suppuration. — Trephin- 
ing or  Opening  the  Mastoid. — Cases. — Statistics. — Historical  Account  of  the 
Operation,  .............  496 

CHAPTER  XIX. 

THE  CONSEQUENCES  OF  CHEONIC  SUPPURATION  OF  THE  MIDDLE 
EAE—  (Concluded).—  NEUEALGIA  OF  THE  MIDDLE  EAE. 

Caries  and  Necrosis  of  the  Temporal  Bone. — Cases. — Treatment  by  Operation  and 
Internal  Medication. — Fatal  Hemorrhage. — Cerebral  Abscess. — Pyaemia. — 
Paralysis. — The  Ophthalmoscope  in  detecting  Cerebral  Disease  of  Aural 
Origin. — Neuralgia  of  the  Middle  Ear, .  545 

CHAPTER  XX. 
ANATOMY  AND  PHYSIOLOGY  OF  THE  INTERNAL  EAE. 

The  Vestibule,  Semi-circular  Canals,  Cochlea,  and  Auditory  Nerve. — Physiology 
of  the  Internal  Ear, 591 

CHAPTER   XXL 
DISEASES   OF  THE   INTEENAL  EAR. 

Difficulty  in  Diagnosis. — Clinical  and  Pathological  Advances. — Differentiation  be- 
tween Diseases  of  Middle  and  Internal  Ear. — Nervousness  and  Nervous  Deaf- 
ness.— Symptoms  of  Primary  Disease  of  the  Cochlea. — Acoustic  Neuritis. — 
Atrophy  of  the  Acoustic  Nerve. — Cases. — The  Tuning-fork  in  Diagnosis. — 
Deafness  to  Certain  Tones. — Double  Hearing. — Electricity. — Syphilitic  Dis- 
ease of  the  Cochlea. — Cochlitis.— Cases,  ........  612 

CHAPTER   XXII. 
DISEASES  OF  THE  INTERNAL  EAR— (Concluded). 

The  Effects  of  Quinine. — Cerebro-spinal  Meningitis. — Meningitis. — Disease  of  the 
Spinal  Cord. — Parotitis. — Acute  Inflammation  of  Membranous  Labyrinth  mis- 
taken for  Cerebro-spinal  Meningitis. — Hemorrhages  and  Effusions. — Injuries. 
— Concussions. — Aneurism  and  Tumors. — Disease  of  Semi-circular  Canals. — 
Pathology. — Treatment, .  641 

CHAPTER  XXIII. 
DEAF-MUTEISM— MECHANICAL  ASSISTANCE  TO  THE  HEARING. 

Acquired  and  Congenital  Cases.  —  At  what  Age  are  Children  Conscious  of  Sounds  ? 
— Causes. — Tables  of  Examination  of  147  Cases. — Hearing-trumpets. — Audi- 
phone,  ..............  685 

INDEX  OF  AUTHOES, 725 

GENEEAL  INDEX, 731 

DESCEIPTION  OF  THE  CHEOMO-LITHOGEAPHS,  .  743 


LIST  OF  WOOD-CUTS. 


1.  Tuning-fork, 54 

2.  Blake's  Tuning-fork, 57 

3.  Angular  Forceps,     ............  59 

4.  Gruber's  Speculum, 60 

5.  Method  of  holding  the  Speculum  in  Position,         ......  61 

6.  Method  of  Examining  the  Auditory  Canal  and  Membrana  Tympani,       .        .  62 

7.  Collin's  Lamp, 63 

8.  Forehead  Band, 63 

8&.  Electric  Lamp  for  Illuminating  Ear,      ........  64 

9.  Blake's  Operating  Otoscope, 65 

10.  Hinge  Speculum,     ............  66 

11.  Turck's  Speculum, 66 

12.  Anterior  Nares  Speculum,       ..........  68 

13.  Goodwillie's  Nasal  Speculum,         .........  68 

13a.  Elsberg's  Nasal  Speculum,     ...        i        ......  69 

14.  Eustachian  Catheters,  actual  size,    .........  70 

15.  Introduction  of  Eustachian  Catheter, 71 

16.  The  Eustachian  Catheter  in  Position,       ........  72 

17.  Air-bag, 73 

18.  Diagnostic  Tube,      ............  73 

19.  Method  of  Using  Politzer's  Apparatus  (with  box  for  containing  iodine  or  other 

evaporating  substance),  ...........  75 

20.  Dr.  Allen's  Xose-pads  for  Politzer's  Apparatus,         ......  76 

21.  The  Auricle, • 81 

22.  Profile  View  of  the  Skull  with  the  Skeleton  or  Cartilage  of  the  Auricle,  as 

well  as  that  of  the  External  Auditory  Canal,  .......  82 

23.  Muscles  of  the  External  Ear, 85 

24.  View  of  the  Cartilage  and  Muscles  on  the  Posterior  Surface  of  the  Auricle,  86 

25.  The  Muscles  of  the  Head, 90 

26.  Section  through  the  External  Meatus  and  the  Ear  at  the  Point  of  Junction  of 

the  Cartilage  of  the  Auricle  with  that  of  the  Auditory  Canal,         .         .         .91 

27.  Horizontal  Section  of  the  Head  through  the  External  Auditory  Canal,    .         .  92 

28.  Annulus  Tympanicus, 92 

29.  Cast  of  Auditory  Canal  and  Adjacent  Parts,     .......  93 

30.  Section  of  Left  Temporal  Bone, 93 

31.  External  Surface  Left  Temporal  Bone, 95 

32.  Case  of  Prominence  of  Auricles  (front  view),  .......  98 

33.  Case  of  Prominence  of  Auricles  (posterior  view),     ......  99 

34.  35.  Deformity  of  Auricles, 101 

36.  Othaematoma.     From  a  photograph  taken  from  a  plaster  cast  when  the  tume- 

faction was  greatest,       ...........  108 

37.  The  same  Ear  after  Rupture  and  Contraction  had  taken  place,        .         .         .  108 


XX  LIST   OF   WOOD-CUTS. 

*'<*•  PAGE 

38.  Showing  Amount  of  Contraction  after  Rupture  of  Cyst, 100 

39.  Shows  Separation  of  Perichondrium  from  Cartilage, 109 

40.  Auricle  Deformed  by  Inflammation, 113 

41.  Tumor  of  the  Anterior  Part  of  Auricle  and  Auditory  Canal,    .         .         .         .117 

42.  Improved  Fountain  Syringe, 128 

43.  Fayette  Douche, 129 

44.  Syringe  for  the  Ear,       - 133 

45.  Reservoir  Syringe, 133 

46.  Method  of  Syringing  the  Ear, .   134 

47.  Aspergillus  Nigricaus,      . 147 

48.  Aspergillus  Flavescens, ;         .         .148 

49.  Specimen  of  the  Spores  and  fully  developed  Growth  of  the  Aspergillus  Fla- 

vescens,         .         .         •         •         •         •         • 149 

50.  Penicillium 150 

51.  Otomyces  Purpureus, 150 

52.  The  Right  Temporal  Bone,  without  the  Petrous  Portion  in  connection  with 

Ossicula  Auditus  of  a  Newly-born  Child,  seen  from  within,         .         .         .  214 

53.  Left  Temporal  Bone  of  the  same  Subjecl  as  preceding  figure,         .         .         .  214 

54.  Section  through  Tympanic  Cavity,  Left  Side, 215 

55.  56.  View  of  Membrana  Tympani,   showing  Handle  of  Malleus  and  Trian- 

gular spot  of  Light,        ...........  219 

57.  Vertical  Section  of  Fibrous  Layer  of  the  Membrana  Tympani,        .         .         .221 

58.  The  Membrana  Tympani,  in  connection  with  the  Ossicula  Auditus  of  the 

Right  Temporal  Bone,  .  225 

59.  Temporal  Bone  of  Left  Side  (inner  view), 226 

60.  The  Right  Temporal  Bone,  with  the  Membrana  Tympani  and  Ossicula  Au- 

ditus of  an  Adult, 229 

61.  Section  of  Right  Temporal  Bone, 230 

62.  Section  through  Tympanic  Cavity,  Left  Temporal  Bone 231 

63.  Tympanic  Cavity  with  Ossicles  in  situ, 232 

64.  Anterior  Surface  of  Malleus  and  Incus  Articulated, 232 

65.  Ossicles  of  the  Tympanum, 233 

66.  Posterior  Surface  of  the  Malleus,  Incus,  and  Stapes  Articulated,     .         .         .  233 

67.  Vertical  Section  through  the  Right  Temporal  Bone, 239 

68.  External  Surface  of  Left  Mastoid  Bone, 240 

69.  Vertical  Section  through  Right  Temporal  Bone,      ......  240 

70.  Vertical  Section  of  Left  Temporal  Bone, 241 

71.  Section  of  the  Head,  showing  the  Divisions  of  the  Ear  and  Naso-pharyngeal 

Cavity, 244 

72.  Transverse  Section  of  Upper  Part  of  the  Eustachian  Tube,     ....  245 

73.  Transverse  Section  through  Lower  End  of  the  Eustachian  Tube,     .         .         .   246 

74.  Same  as  last, 246 

75.  Vertical  Section,  showing  the  Mouth  of  Eustachian  Tube  and  Rosenm  filler's 

Fossa, 247 

76.  Transverse  Section  of  Eustachian  Tube  and  Surrounding  Parts,      .         .         .  248 

77.  Section  of  the  Upper  Third  of  the  Eustachian  Tube, 249 

78.  Section  of  the  Middle  Third  of  the  Eustachian  Tube, 250 

79.  Fracture  of  Handle  of  Malleus,  displaced, 277 

80.  Fracture  of  Handle  of  Malleus,  reduced,         .......  277 

81.  Paracentesis  Needle,         ...........  289 

82.  Diseases  of  Bone  in  Case  of  Meningitis  following  Acute  Suppuration  of  Mid- 

dle Ear, .315 


LIST   OF   WOOD-CUTS.  XXI 


83.  Siegle's  "Otoscope"  with  Ely's  Attachment  of  a  Syringe,       .         .         .         .368 

84.  Pharyngitis  Granulosa,  ...........  370 

85.  Posterior  Nares  Syringe,         ..........  383 

86.  Davidson's  Syringe  with  a  Nozzle  to  go  below  the  Soft  Palate,         .         .         .  384 

87.  Vertical  Section  of  Bones  of  Face  (posterior  half),  ......  388 

88.  Vertical  Section  of  Bones  of  Face  (anterior  half), 390 

89.  Nebulizer  for  Nostrils  and  Pharynx, 391 

90.  Tonsil  Knife, 395 

91.  Tonsil  Forceps, 395 

92.  Apparatus  for  Steaming  the  Middle  Ear, 399 

93.  Bottle  for  the  Generation  of  Vapor  of  Iodine.      An  ordinary  air-bag  is  used 

for  forcing  the  vapor  into  the  catheter,         .......  400 

94.  Hackley's  Eustachian  Nebulizer,     .........  404 

95.  Proat's  Knife 433 

95«.  Delstanche's  Masseur, 439 

96.  Vessel  Used  in  Syringing  the  Ear,  .........  454 

97.  Buck's  Pipette, 455 

98.  Knapp's  Powder-blower,          ..........  457 

99.  Toynbee's  Artificial  Membrana  Tympani,        .......  465 

100.  Method  of  Inserting  Artificial  Membrana  Tympani  (Toynbee),        .         .          .  406 

101.  Section  of  Aural  Polypus, 476 

102.  Section  of  Aural  Polypus, 477 

103.  Section  of  Aural  Polypus, 478 

104.  Blake's  Modification  of  Wilde's  Snare  with  Paracentesis  Needle,   .         .         .  481 

105.  Scissors  for  the  Removal  of  Aural  Polypi,       .......  481 

106.  Buck's  Curettes  for  Clearing  Auditory  Canal  and  Tympanum,        .         .         .  482 

107.  Schwartze's  Chisels  for  Opening  the  Mastoid,         ......  507 

107a.  Wilson's  Trephine, 543 

1075.  Petrous  Portion  of  the  Temporal  Bone  Removed,         .....  550 
107c.  Mastoid  Fistula  following  Necrosis,        ........  551 

108.  Left  Temporal  Bone,  Exterior  View  (Necrosis),       ......  553 

109.  Left  Temporal  Bone,  Inner  Surface,        ........  553 

110.  Left  Temporal  Bone,   Sawed  through  External  Meatus,   Middle  Ear,    and 

Cochlea,         .............  554 

111.  Right  Temporal  Bone,  from  Case  V. ,  showing  the  Cranial   Surface  of  the 

Bone,    ..............  554 

112.  Caries  of  Squamous  and  Mastoid  Portion  of  Temporal  Bone,  ....  555 

113.  Caries  of  Petrous  Portion  of  Right  Temporal  Bone,         .....  557 

114.  Caries  of  Lateral  Sinus  of  Right  Temporal  Bone,     ......  558 

115.  Caries  of  Squamous  Portion  of  Temporal  Bone,       ......  558 

116.  A  Diagram  designed  to  show  the  Relations  of  the  Tympanic  Cavity  to  the  Mas- 

toid Cells,  the  Jugular  Fossa  and  the  Cavity  of  the  Cranium,        .         .         .   560 

117.  The  Left  Vestibule,  with  the  Semi-circular  Canals,  from  an  Adult,  seen  from. 

within,  ..............  592 

118.  The  Vestibule, 592 

119.  Section  of  Temporal  Bone  of  Right  Side  through  the  Cochlea,       .         .         .  594 

120.  Osseous  Cochlea  and  Semi-circular  Canals  with  Stapes  Bone,    Left  Ear  of 

Adult, 594 

121.  Right  Osseous  Vestibule,  Semi-circular  Canals,  Cochlea,  and  Ossicula  Auditus 

of  Newly  Born,     ............  594 

122.  The  Right  Osseous  Labyrinth  <i£  a  Newly  Born  Subject,  opened  on  its  Poste- 

rior Surface,         ............  595 


XX11  LIST   OF   WOOD-CUTS. 

no.  PAGE 

123.  Section  of  Right  Temporal  Bone,  showing  the  Osseous  Semi-circular  Canals,  . .  595 

124.  Osseous  Cochlea  (Right)  of  the  Newly  Born,  opened  from  the  Outer  Surface,  .  596 

125.  Section  through  Cochlea  and  Vestibule,  ........  597 

126.  Periosteum  of  Labyrinth, 598 

127.  Periosteum  of  the  Outer  Wall  of  the  Cochlea, 598 

128.  Utricle  and  Membranous  Semi-circular  Canals  of  the  Left  Side,     .         .         .  599 

129.  A  Piece  of  the  Wall  of  the  Utricle,  with  the  Otoliths, 599 

130.  Transverse  Section  of  a  Cochlear  Spiral,  ........  601 

131.  From  the  Terminal  Auditory  Apparatus  of  a  Cat,   ......  603 

132.  Profile  View  of  Outer  and  Inner  Rods, .  604 

133.  Membrana  Basilaris,  with  the  Terminal  Nerve-Fibres, 604 

134.  Expansion  of  the  Right  Cochlear  Nerve,  seen  from  the  Base  of  the  Cochlea,  .  605 

135.  A  Diagram  designed  to  Illustrate  the  Physiology  of  the  Labyrinth,         .         .  608 

136.  Hearing-trumpets,  .         .         .      * 719 

137.  Auricles, 719 

138.  The  Audiphone  in  its  Natural  Position  ;  used  as  a  Fan,         ....  720 

139.  The  Audiphone  in  Tension  ;  the  Proper  Position  for  Hearing,       .         .         .  720 

140.  Method  of  Using  the  Audiphone, 720 


A  TEEATISE  ON 

THE    DISEASES    OF    THE    EAR. 


CHAPTER   I. 

A  SKETCH  OF  THE  PEOGEESS  OF  OTOLOGY  WITH  A  BIBLI- 

OGEAPHY. 

fastness  of  Otological  Literature. — Apathy  in  regard  to  Diseases  of  the  Ear. — Wilde 
the  Reformer  of  the  Science. — Carl  Gustav  Lincke  and  his  Handbook. — Papyrus 
Ebers. — Hippocrates  and  his  Knowledge  of  the  Ear. — Alcmaeori  the  Discoverer  of 
the  Eustachian  Tube. — Rufus  of  Ephesus. — Aristotle. — Discoveries  in  the  Time  of 
the  Ptolemys. — Galen  and  the  Want  of  Progress  in  his  Time. — Achillini  and  Beren- 
gario  describe  the  Ossicles. — Vesalius  the  most  accurate  Anatomist  of  his  Day. — In- 
grassia,  Columbo,  and  Eustachius  each  claim  Discovery  of  Stapes. — Fallopius  and 
his  Career. — Anatomical  Writings  of  Eustachius. — First  Monograph  pn  Anatomy  of 
the  Ear. — Constant  Varolius. — Fabricius  of  Aquapendente. — Valsalva. — Casserius, 
a  Pupil  and  Rival  of  Fabricius. — Stenon  describes  Ceruminous  Glands. — Discovery 
of  Helicotrema. — Du  Verney  and  his  Plates. — Cotugno  and  the  Aqueducts. — 
Meckel. — Rivinian  Foramen. — Hyrtl  and  Bochdalek  upon  its  Existence.— Ruysch. 
— Brendel  and  Zinn. — Scarpa  upon  the  Internal  Ear. — Saunders,  Todd,  and  others. 
— Monro's  Claim  to  have  first  traced  the  Nerves  into  the  Cochlea,  Vestibule,  and 
Semicircular  Canals. — Everard  Home's  Account  of  the  Membrana  Tympani. — 
Soemmering.—  Shrapnell. — Thomas  Buchanan  on  the  Importance  of  Cerumen. — 
Wharton  Jones. — Discoveries  of  Toynbee. — Troltsch,  Politzer,  Lucse,  and  others. 
— The  Organ  of  Corti  and  its  Discoverer. — Pathological  Anatomy  of  the  Ear. — Prog- 
ress in  Treatment  of  Aural  Disease. — Herodotus  on  Specialists. — The  Remedies 
suggested  by  Hippocrates. — Celsus. — Archigenes  on  Venesection  and  Foreign 
Bodies. — Galen  on  Noise. — Peculiar  Method  of  removing  Foreign  Body  from  Ear. 
— Paulus  ^Egineta,his  Classification  and  Operation.— Arabians,  their  Knowledge  of 
Otology. — Paracelsus  burning  Books  of  his  Predecessors. — Capivacci  on  Differential 
Diagnosis. — Ambroise  Pare  first  uses  a  Syringe  for  the  Ear. —The  Education  of 
Deaf  Mutes. — Old  Method  of  detecting  Inspissated  Cerumen. — Lusitanus  on  cut- 
ting off  Ears  of  Thieves. — Fabricius  of  Hilden.— Thomas  Willis,  his  Observations 
on  Hearing  in  a  Noise. — The  Therapeutical  Work  of  Valsalva. — Petit  on  Caries  of 
the  Mastoid. — The  Discovery  of  the  Eustachian  Catheter. — Guyot,  Cleland. — Per- 
foration of  the  Membrana  Tympani. — Trephining  the  Mastoid. — Sir  Astley  Cooper. 
— Saunders  on  Perforation  of  the  Membrana  Tympani.  — First  Infirmary  for  Dis- 
1 


eases  of  the  Ear. — Saissy,  Itard,  Beck. — Sketch  of  Kramer's  Career. — Discovery  of 
Artificial  Membrana  Tympani. — Yearsley. — Wilde  and  his  great  Work  in  Otology. 
— The  Text-books  of  Toynbee,  Troltsch,  Erhard. — Modern  Text-books  and  Jour- 
n  als.  — Bibliography . 

THERE  is  perhaps  no  department  of  the  art  and  science  of  medi- 
cine, in  which  there  has  been  so  much  literature,  with  so  little 
exact,  or  as  we  say,  scientific  knowledge,  as  that  which  wTas 
formerly  known  as  aural  medicine  and  surgery,  but  which  is 
better  designated  by  the  term  Otology. 

Hundreds  and  perhaps  thousands  of  volumes  have  been 
written  on  the  anatomy,  physiology,  and  diseases  of  the  ear, 
and  yet  until  the  age  of  Valsalva,  the  seventeenth  century,  the 
treatment  of  the  affections  of  the  organ  of  hearing  was  purely 
empirical,  while  the  knowledge  of  its  anatomy  and  physiology 
was  generally  incorrect  and  superficial.  Even  after  the  inves- 
tigations of  the  famous  Italian,  investigations  which  occupied 
sixteen  years  of  his  life,  and  the  subsequent  anatomical  dis- 
coveries of  the  eighteenth  century,  it  was  reserved  for  our  own 
day  and  generation  to  place  the  science  of  otology,  or  the  knowl- 
edge of  the  anatomy,  physiology,  and  diseases  of  the  ear,  on  a 
level  with  that  of  other  fields  of  labor  in  medicine. 

A  singular  apathy  in  regard  to  the  maladies  of  one  of  the 
most  important  organs  of  the  body,  an  inexplicable  ignorance 
as  to  their  results,  a  most  irrational  and  empirical  manner  of 
treatment,  have  been  our  heritage  from  the  fathers.  Probably 
to-day,  in  the  closing  years  of  the  nineteenth  century,  aural 
medicine  and  surgery  is  more  generally  regarded  from  the 
standpoint  of  the  errorists  of  the  dark  ages,  than  is  any  other 
department  of  our  science  and  art.  It  is  to  be  feared,  that  even 
now,  many  wise  and  skilful  practitioners  do  not  know,  that  to 
drop  stimulating  or  even  anodyne  applications  upon  a  membrane 
which  they  have  never  examined,  to  probe  an  ear  for  wax  that 
they  cannot  see,  are  purely  empirical  practices  which  every  con- 
scientious physician  should  hold  in  abhorrence. 

The  great  reformer  of  this  science,  Wilde,1  wrote,  as  late 
as  1853,  that  "the  affections  of  the  ear,  whether  functional  or 
organic,  are  spoken  of,  lectured  on,  written  of,  and  described 
(even  in  great  part  to  the  present  day),  not  according  to  the  laws 
of  pathology  which  regulate  other  diseases,  but  by  a  single  symp- 
tom, that  of  deafness" 

It  is  with  no  desire  to  recount  the  details  of  the  long  and 
painful  story  of  the  gropings  in  the  dark,  which  have  charac- 
terized the  teachings  on  otology  from  the  days  of  the  philoso- 

1  Aural  Surgery,  English  edition,  p.  7. 


PROGRESS   OF   OTOLOGY. 

pher  of  Cos,  until  the  seventeenth  century,  that  I  attempt  an 
historical  sketch  of  our  progress  up  to  our  present  position.  I 
have  neither  the  time  nor  the  facilities  for  such  a  task  ;  but  an 
endeavor  will  be  made  to  sketch  the  history  of  otology,  from  the 
sources  to  which  I  have  access,  in  such  a  manner  as  to  show 
the  obstacles  which,  until  twenty  years  ago,  have  prevented 
the  satisfactory  progress  of  the  science. 

I  must  first  of  all,  make  especial  acknowledgment  of  my  in- 
debtedness for  a  large  part  of  my  material,  to  that  valuable  com- 
pendium, "Lincke's  Handbuch  der  Ohrenheilkunde."  '  I  have, 
however,  consulted  the  original  authorities  as  far  as  the  best 
medical  library  of  New  York — that  of  the  New  York  Hospital — 
and  my  own  would  permit.  Where  no  other  authority  is  given  in 
a  foot-note,  Lincke  is  the  one  from  which  I  quote,  and  often  by  an 
exact  translation.  The  discoveries  and  teachings  in  the  anatomy 
of  the  ear  will  be  first  reviewed,  after  which  the  progress  in  the 
examination  and  treatment  of  its  diseases  will  be  noted. 

For  the  convenience  of  the  reader,  I  have  given  the  titles  of 
the  works  consulted,  both  at  the  foot  of  the  page,  and  in  the  for- 
mal bibliography. 

In  the  Astor  Library  in  the  city  of  New  York,  is  a  fac-simile 
copy  of  one  of  the  oldest  medical  treatises  that  is  known  to  ex- 
ist. The  original  is  a  papyrus  book  in  the  Royal  Saxon  Library 
of  Leipsic.  It  is  called  the  "  Papyrus  Ebers,"  it  having  been  ob- 
tained by  the  celebrated  Egyptologist,  George  Ebers,  while  in 
Thebes,  from  a  certain  native,  who  is  said  to  have  taken  it.  about 
the  year  1861,  from  among  the  bones  of  an  Egyptian  who  had 
been  buried  more  than  thirty-four  hundred  years.  This  book  is 
entitled  "  The  Hermetic  Book  of  the  Medicines  of  the  Ancient 
Egyptians."2  It  is  written  upon  papyrus,  three-fourths  of  a 
meter  wide  and  twenty  meters  long.  It  is  one  of  the  six  medical 
works  named  by  Clement  of  Alexandria. 

Among  other  subjects  treated  of  in  this  large  volume,  is  a 
monograph  upon  "  medicines  for  ears  hard  of  hearing,"  and  "  for 
ears  from  which  there  is  a  putrid  discharge."  Inasmuch  as  the 
translation  of  the  hieroglyphic  language  of  the  manuscript  only 
extends,  as  yet,  to  the  table  of  contents,  we  cannot  know  whether 
the  Egyptian  priests  had  a  better  knowledge  of  the  proper  treat- 
ment of  the  ear,  than  was  possessed  by  their  Greek  and  Roman 
successors  many  centuries  later. 

1  Carl  Gustav  Lincke  was  a  teacher  of  otology  in  the  University  of  Leipsic  from 
Easter,  1837,  to  Easter,  1840.  His  name  appears  in  the  catalogue  of  that  University  in_ 
the  sessions  of  1845-46  for  the  last  time. 

9  Papyrus  Ebers.  Das  Hermetische  Buch  iiber  die  Arzneimittel  der  alten  Aegypten. 
Leipzig,  1875. 


4  A   SKETCH   OF   THE 

A  papyrus  of  later  date  is  in  the  Berlin  Museum.  This  has 
been  translated  by  Dr.  G.  Brugsh,'  and  there  are  also  similar 
manuscripts  in  the  museums  in  Leyden,  London,  and  Turin. 

PROGRESS  IN  THE  ANATOMY  OF  THE  EAR. 

Hippocrates  probably  knew  very  little  of  the  anatomy  of  the 
ear,  although  one  passage  is  found  in  his  works  which  indicates 
that  the  membrana  tympani  was  not  unknown  to  him.2 

Alcmseon,  a  disciple  of  Pythagoras  (570-504  B.C.),  is  said  to 
have  had  a  knowledge  of  the  art  of  dissecting  the  human  body, 
to  have  known  the  construction  of  the  ear,  and  to  have  antici- 
pated Eustachius  in  the  discovery  of  the  passage  leading  from 
the  tympanic  cavity  to  the  pharynx.  Lincke  thinks  that  this 
much  cannot  be  conceded  to  Alcmseon,  since  it  rests  only  upon 
his  assertion,  brought  forth  and  denied  by  Aristotle,  that  goats 
breathed  through  their  ears.  This  statement  of  Alcmseon  is  said 
to  have  rested  upon  other  grounds  than  the  existence  of  what 
we  call  the  Eustachian  tube.  Plutarch  says,  however,  that 
Empedocles  discovered  a  snail-shaped  cartilage  in  the  ear 
(KoxAioiSqs  xovSpos),  which  he  considered  the  real  organ  of  hearing, 
and  that  the  vibrations  of  the  air  caused  it  to  give  forth  a  tone 
which  was  then  perceived  by  the  soul. 

The  knowledge  of  Aristotle  (384-322  B.C.)  as  to  the  anatomy 
of  the  ear  did  not  go  beyond  the  membrana  tympani.  But  Aris- 
totle made  numerous  dissections  of  animals  and  many  impor- 
tant discoveries  in  anatomy.  There  are  indications  that  he  had 
an  indefinite  idea  of  the  Eustachian  tube. 

In  the  time  of  the  Ptolemys  in  Egypt,  when  dissections  of 
the  human  body  were  instituted,  Erasistratus  made  the  discovery 
that  the  nerves  originate  in  the  brain,  and  he  traced  them  so 
exactly  to  their  origin  that  we  find  the  acoustic  nerve  properly 
indicated  in  his  representations. 

Rufus  of  Ephesus  (A.D.  98-117),  who  was  the  first  medical 
lexicographer,  and  who  lived  in  the  age  of  Pliny,3  used  the  names 
helix,  lobe,  tragus,  and  anti-tragus,  which  are  still  employed  to 
describe  the  different  parts  of  the  auricle.  He  probably  obtained 
them  from  Herophilus,  a  contemporary  of  Erasisr^atus. 

Marinus,  the  preceptor  of  Galen,  and  whom  Galen  named 

1  Hartmann  :  Lehrbuch,  Einleitung. 
'  Tb  Sfftua  rb  irpj»?  rrj  OLKOT/J 

irpbs  rSi  vffrtdi  ru  ir/cATjpw  \tvrbf 

Iffnv  &<ritfp  apaxviov,  £ripora  -rov 

TOV  a\\ou  Sepjuaroy. 
3  History  of  Medicine  (Dunglison),  p.  169 


PROGRESS   OF   OTOLOGY.  5 

the  restorer  of  anatomy,  called  the  acoustic  and  facial  nerves 
one,  under  the  name  of  the  fifth  pair. 

Galen  (A.D.  130-200)  does  not  seem  to  have  made  any  great 
advance  in  anatomical  studies,  and  they  were  greatly  neglected 
down  to  the  fifteenth  century.  The  darkness  of  the  blind  lead- 
ing the  blind  is  scarcely  broken  for  thirteen  hundred  years. 
What  Galen  wrote,  was  authority,  and  naught  else.  One  valiant 
and  polemic  skeptic  in  medicine,  would  have  effected  more  good 
during  these  centuries  than  all  the  ponderous  tomes  that  were 
written  by  philosophers  who  reasoned  upon  premises  that  had 
never  been  thoroughly  established.  As  late  as  1559,  one  Doctor 
Geynes  was  called  before  the  College  of  Physicians  in  London 
for  impugning  the  fallibility  of  Galen.  On  his  acknowledgment 
of  his  error,  however,  he  was  again  received  into  the  college.1 
The  strong  arm  of  the  church,  in  the  dark  ages,  prevented  ana- 
tomical investigations  on  the  human  cadaver,  and  for  hundreds 
of  years  anatomical  knowledge  remained  at  a  standstill. 

Galen,  however,  corrected  the  error  of  his  preceptor  in  think- 
ing that  the  facial  and  acoustic  nerves  were  one,  and  showed 
that  the  latter  entered  the  meatus  auditorius  interims,  a  passage 
which  his  predecessors  had  regarded  as  impermeable.  He  gives 
no  account  of  the  anatomy  of  the  internal  ear,  although  he  com- 
pares it  to  a  labyrinth,  a  name  which  Fallopius,  fourteen  hun- 
dred years  later,  fastened  on  it  forever.  He  believed  that  the 
external  auditory  canal  extended  to  the  dura  mater  and  touched 
the  auditory  nerve. 

There  is  no  record  of  the  ossicula  auditus  until  the  fifteenth 
century.  An  Italian  anatomist,  Alexander  Achillini,  generally 
has  the  credit  of  discovering  the  little  bones,  but  it  is  probable 
that  he  and  Jacob  Berengario  first  described  them,  although 
they  did  not  discover  them.  This  is  the  opinion  of  the  great 
anatomist,  Bartholomeo  Eustachio.  The  discovery  of  the  ossi- 
cula auditus  did  not  at  first  include  the  third  and  last  of  the 
chain. 

Berengario  also  first  described  the  membrana  tympani  "  with 
exactness."  The  exactness  of  his  knowledge,  may  be  shown  by 
the  fact,  that  he  was  doubtful  whether  the  origin  of  the  mem- 
brane was  in  the  acoustic  nerve  or  the  meninges  of  the  brain. 

Andreas  Vesalius  (1514-1564),  who  is  said  to  have  been  the 
most  accurate  anatomist  of  his  day,2  described  the  long  process 
of  the  malleus,  the  Eustachian  tube,  the  vestibule,  and  the  semi- 
circular canals.  He  was  a  reformer  in  anatomical  learning,  he 

1  Chambers's  Encyclopaedia,  American  edition.     Article,  Galenus  or  Galen, 
8  Dunglison :  History  of  Medicine. 


6  A   SKETCH   OF   THE 

boldly  attacked  the  views  of  Galen,  showing  the  errors  in  his 
teachings.  His  anatomical  plates  were  made  from  drawings  by 
the  best  masters.  They  were  published  in  a  folio  edition  at 
Basle  in  1542. 

The  honor  of  the  discovery  of  the  stapes  bone  is  claimed  by 
no  less  than  three  anatomists,  viz.  :  Ingrassia,  Columbo,  and 
the  renowned  Bartholomeus  Eustachius  (1604).  The  first  named 
wrote  commentaries  upon  Galen's  works,  that  were  published 
long  after  his  death.  He  claims  to  have  shown  the  bone  to  his 
scholars  in  1546,  at  Naples.  Fallopio,  or  Fallopius,  at  one  time 
claimed  to  have  had  a  part  in  the  discovery  of  the  ossicle,  but 
in  view  of  his  own  greater  discoveries  he  finally  relinquished  his 
claim  in  favor  of  Ingrassia,  after  one  of  the  latters  pupils  had 
assured  him,  that  Ingrassia  had  actually  discovered  and  named 
the  bone.  The  weight  of  evidence,  in  spite  of  the  opinion  of 
Eustachius,  seems  to  lean  toward  the  side  of  Ingrassia  as  having 
the  honor  of  the  discovery.  Anatomical  and  geographical  sci- 
ence were  about  this  time  in  an  embarrassed  position  from  the 
claims  of  priority  of  their  discoverers.  Fallopius  did  good  ser- 
vice, in  the  study  of  the  anatomy  of  the  ear,  in  describing  the 
tympanic  cavity  more  accurately,  the  two  fenestrse,  and  their 
communication  with  the  vestibule  and  the  cochlea  respectively. 

The  anatomical  writings  of  Eustachius  were  published  in  1563, 
before  his  death,  but  the  Tabulae,  Anatomicce  did  not  appear  un- 
til 1714,  a  century  and  a  half  afterward.  He  was  probably  unable 
to  publish  these  on  account  of  his  poverty.  Of  posthumous  fame 
he  has  had  a  large  share.  His  anatomical  plates  were  repro- 
duced with  Dutch  and  German  commentaries — in  the  latter 
language  as  late  as  1800.  The  Venetian  edition  of  his  works  is  a 
beautiful  specimen  of  printing.  The  part  referring  to  the  ear 
occupies  only  seventeen  pages — yet  his  fame  now  rests  chiefly 
upon  his  description  of  the  Eustachian  tube.1 

Gabriel  Fallopius  (1523-1562),  of  Modena,  died  in  the  bloom 
of  youth,  at  thirty-nine  years  of  age,2  but  he  lived  long  enough 
to  accomplish  much  for  anatomical  science.  He  showed,  among 
other  valuable  points  in  the  anatomy  of  the  ear,  that  the  mastoid 
cells  communicated  with  the  cavity  of  the  tympanum.  He  de- 
scribed the  fenestrse  rotunda  and  ovalis,  and  gave  his  name  to 
the  canal  in  which  the  facial  nerve  runs  in  its  passage  through 
the  cavity  of  the  tympanum — acquceductus  Fallopii.* 

The  great  Cuvier  regarded  Vesalius,  Eustachius,  and  Fallo- 

1  Bartholomaei  Eustachii :  Opuscula  Anatomica  Anatomica,  MDLXHI. 

2  Chambers's  Encyclopaedia,  p.  233. 

3  Gabrielis  Falloppii :  Opera  Omnia,     Francfurti,  MDC. 


PKOGKESS   OF   OTOLOGY.  7 

plus  as  the  three  anatomists  of  the  sixteenth  century,  to  whom 
belongs  the  honor  of  having  restored  this  science. 

Bartholomeo  Eustachio  (1500-1574)  described  the  tensor  tym- 
pani  as  well  as  the  stapedius  muscle.  He  also  gave  a  more  ex- 
act account  of  the  tube  leading  from  the  pharynx  to  the  middle 
ear,  which  is  called  the  Eustachian  tube,  although  it  was  dis- 
covered by  Yesalius.  He  described  the  modiolus  of  the  cochlea, 
and  gave  a  good  representation  of  the  membranous  zone.  He 
also  recognized  the  three  portions  of  the  facial  nerve. 

The  first  monograph  on  the  anatomy  of  the  ear  was  from  the 
pen  of  Volcher  Koiter  (1587),  a  student  of  Fallopius.  It  con- 
tained no  original  observations,  however. 

Constant  Varolius  (1543-1573), '  so  well  known  from  his  de- 
scriptions of  the  brain,  made  the  singular  mistake  of  supposing 
that  the  muscles  of  the  cavity  of  the  tympanum  were  nerves 
which  were  torn  by  the  sawing  through  of  the  bone.  Subse- 
quently he  admitted  this  error  ;  but  he  went  so  far  to  the  other 
side,  as  to  say  that  the  tensor  and  laxator  tympani  muscles  could 
be  moved  at  will. 

Lincke  does  not  think  that  the  famous  Fabricius  of  Aquapen- 
dente  (1537-1619)  contributed  very  much  to  our  knowledge  of 
the  anatomy  of  the  ear,  while  he  led  many  away  into  error  as 
to  some  points.  For  example,  he  thought  that  the  chorda  tym- 
pani nerve  was  a  peculiar  body,  and  not  a  nerve.  At  any  rate, 
Fabricius  did  good  service  by  his  labors  as  a  comparative  anato- 
mist, and  it  should  be  remembered  that  he  was  the  instructor  of 
the  discoverer  of  the  circulation  of  the  blood. 

The  folio  edition  of  his  works,  published  in  1600, 3  contains  a 
very  systematic  and  clear  account  of  the  anatomy  of  the  ear  as 
then  understood.  He  gives  the  name  myrinx,  as  well  as  my- 
ringa — whence  our  myringitis — to  the  membrana  tympani.  Fa- 
bricius ascribes  the  discovery  of  the  Eustachian  tube  to  an 
earlier  date  than  that  which  assigns  it  to  Eustachius.  Accord- 
ing to  him  Aristotle  knew  of  it. 

Julius  Casserius  (1593-1609),  who  was  a  professor  in  Venice 
in  1609,  a  pupil  and  subsequently  a  rival  of  Fabricius,  described 
the  fissures  that  make  the  cartilaginous  portion  of  the  canal  so 
flexible.  He  and  Fabricius  described  the  laxator  tympani  minor 
in  the  same  year,  and  both  claim  to  have  discovered  it  first. 
Casserius  also  gave  a  better  description  than  had  hitherto  been 
done  of  the  membrana  tympani,  the  ossicula  auditus,  and  the 
labyrinth.  He  was  the  first  to  describe  the  two  and  a  half 
turns  of  the  cochlea  and  the  membranous  zone. 


1  Biographie  Medicale.     Paris. 

y  Heronymi  Fabricii  ab  Aquapendente.     De  Visione,  Voce,  Auditu.    Venetiis,  1600. 


8  A   SKETCH   OF  THE 

The  function  and  physiological  action  of  the  ceruminor." 
glands  were  first  described  by  Nicolaus  Stenon  (1665).  Lincke 
speaks  of  him  as  Stenson  ;  but  this  must  be  a  mistake  in  tran- 
scribing the  name  of  the  great  Danish  anatomist. 

Lincke  ascribes  to  Du  Verney  the  greatest  reputation  of  any 
of  the  anatomists  of  the  seventeenth  century  who  devoted  any 
attention  to  the  ear.  He  threw  new  light  upon  many  dark  sub- 
jects. He  was  the  first  to  give  good  representations  of  the  ceru- 
minous  glands,  the  Eustachian  tubes,  and  the  semicircular 
canals  with  their  five  openings  in  the  vestibule.1  His  plates  are 
particularly  clear. 

Passing  on  to  the  eighteenth  century,  we  find  Antonine  Marie 
Valsalva  rising  up  a  head-and-shoulders  above  the  anatomists  of 
his  age,  and  far  exceeding  his  predecessors  in  the  amount  and 
exactness  of  his  knowledge.  He  devoted  more  than  sixteen 
years  of  his.  life  to  the  study  of  the  anatomy  of  the  ear,  and  for 
the  purpose  of  its  study  dissected  more  than  a  thousand  heads. 
His  master-work  was  a  treatise  on  the  ear.1  This  work  passed 
through  five  editions  in  a  short  time.  He  described  the  attach- 
ment of  the  tensor  tympani  to  the  Eustachian  tube.  He  made 
the  mistake,  however,  of  supposing  that  the  ossicula  auditus 
had  no  periosteum,  and  that  the  cavity  of  the  tympanum  was 
connected  by  many  openings  to  the  cavity  of  the  cranium.  He 
discovered  the  muscle  that  opens  the  Eustachian  tube  and  moves 
the  uvula.  He  also  showed  that  the  fenestra  ovalis  was  covered 
by  membrane.  His  anatomical  plates  show  a  good  knowledge 
of  the  cochlea  and  semi-circular  canals. 

Morgagni  (1682-1771),  himself  an  original  investigator,  the 
founder  of  pathological  anatomy,  a  student  and  friend  of  Val- 
salva, edited  his  master's  work  and  made  some  additions. 

Of  Valsalva's  contributions  to  the  treatment  of  the  ear, 
which  were  quite  as  important  as  his  anatomical  investigations, 
we  shall  have  occasion  to  speak  in  the  second  part  of  this  sketch. 
Valsalva  had  a  rival,  whose  name  the  lapse  of  time  has  well 
nigh  effaced,  Raymond  Vieussens  (1714),  who  also  wrote  a  work 
on  the  ear.  He  gave  new  names  to  various  parts  of  the  organ  ; 
but  his  descriptions  are  said  by  Lincke,  to  be  so  mysterious  that 
his  contemporaries  could  not  understand  them. 

Rivinus  (1717),  professor  in  Leipsic,  observed  an  opening  in 
the  membrana  tympani,  which  he  believed  to  be  a  constant  ana- 
tomical condition.  This  supposed  discovery  excited  the  warm- 

1  Tractatus  de  Organo  Auditus.  par  Dr.  du  Verney.     Nbrembergse,  1684. 
*  Tractatus  de  Aure  Humana.      Lugdunum  Batavorum,  1742.      Also,  the  same. 
Trajecti  ad  Rhenum,  1717. 


PROGRESS   OF   OTOLOGY.  9 

est  discussion  among  such  anatomists  as  Walther,  Ruysch, 
Morgagni,  Cassebohm,  and  Valsalva.  Hyrtl,  until  recently  the 
distinguished  anatomical  teacher  of  Vienna,  thought  that  it  was 
a  rent  in  a  macerated  membrane  ;  but  his  predecessor,  Berres, 
believed  in  its  existence  and  described  it  minutely.1 

Professor  Bochdalek,  of  Prague,  has  revived  the  question,3 
and  has  described  the  foramen  of  Rivinus  as  a  constant  opening 
in  the  membrana  tympani ;  this  author  says  that  there  are  some- 
times two.  It  is,  however,  according  to  Bochdalek,  so  small  as 
not  to  be  seen  without  the  aid  of  a  magnifying  glass. 

In  a  discussion  in  one  of  the  medical  societies  of  Vienna,3 
Professors  von  Patruban,  Gruber,  and  Politzer  unite  in  affirm- 
ing its  existence,  thus  confirming  Bochdalek's  statement. 

The  famous  Ruysch  (1718)  (Frederick),  professor  in  Amster- 
dam, contributed  to  our  knowledge  of  the  distribution  of  the 
vessels  of  the  cavity  of  the  tympanum,  and  corrected  Valsalva's 
statement  that  the  ossicula  were  not  covered  by  periosteum. 

Cassebohm  (1730)  (Joan.  Frid.)  published  a  monograph  upon 
the  ear,  in  six  parts,  which  Lincke  calls  "  a  monument  to  Ger- 
man industry  and  German  spirit  of  inquiry."  "  Ein  Denkmal 
deutschen  Fleisses  und  deutschen  Beobachtungsgeistes."  He 
disproved  Valsalva's  idea  of  the  close  connection  between  the 
cavity  of  the  tympanum  and  the  cerebrum  ;  he  described  the 
cochlea  and  the  development  of  the  auditory  apparatus  in 
the  foetus. 

Brendel  and  Zinn  (1747-1753),  two  Gottingen  anatomists,  the 
latter  of  whom  is  well  known  as  the  describer  of  the  suspensory 
ligament  of  the  lens,  known  as  the  zonula  of  Zinn,  made  further 
investigations  as  to  the  structure  of  the  cochlea. 

Brendel  discovered  the  opening  uniting  the  two  scalse,  the 
helicotrema  of  Breschet.  Zinn  describes  the  opening  through 
which  the  auditory  nerve  enters  the  cochlea. 

It  is  claimed,  in  an  inaugural  thesis  published  in  Erlangen  in 
1754,  that  Casimir  Christopher  Schmiedel,  discovered  the  so- 
called  Jacobson's  nerve. 

Dominic  Cotugno  (1761),  the  discoverer  of  the  fluid  of  the  lab- 
yrinth, won  such  a  reputation  by  his  work  upon  the  internal 
ear  that  he  was  called  to  the  anatomical  chair  at  Naples.  He 
was  the  first  clearly  to  show  that  the  labyrinth  was  filled  with 
fluid,  and  that  this  was  one  of  the  necessities  for  the  perception 
of  sound.  He  described  two  canals,  one  opening  in  the  vesti- 

1  Prager  Viertel.  Jahrschrift,  1806,  I. 

sTroltsch  on  the  Ear,  2d  American  edition,  p.  26. 

3  Monatsschrif t  fur  Ohrenheilkuude,  Jalirgang  III. ,  No.  I. 


10  A   SKETCH   OF   THE 

bule,  the  other  in  the  cochlea,  and  both  communicating  with  the 
cerebral  cavity.  They  were  named  in  his  honor. 

Phil  Friederich  Meckel  confirmed  and  corrected  the  observa- 
tions of  Cotugno  by  injections  of  quicksilver. 

Antonio  Scarpa  (1747-1832),  nearly  thirty  years  after  the  pub- 
lication of  Cotugno's  writings,  issued  a  work  on  the  structure 
of  the  ear,  which  brought  the  knowledge  of  its  inner  arrange- 
ment to  such  a  height,  that  it  seemed  to  his  contemporaries  that 
there  was  little  more  to  be  done.  The  investigations  of  our 
own  day  have  shown  how  premature  was  this  expression. 
Scarpa  wrote  upon  the  fenestra  rotunda,  which  connects  the 
tympanic  cavity  with  the  lamina  spiralis  of  the  cochlea.  He 
described  the  osseous  labyrinth  with  exactness,  the  membra- 
nous labyrinth,  arid  the  expansion  of  the  acoustic  nerve. 

Scarpa  was  secretary  to  the  octogenarian  Morgagni,  when 
the  latter  had  lost  his  sight,  and  he  wrote  letters  of  advice  in 
Latin  at  the  dictation  of  his  blind  preceptor.  His  beautiful  cop- 
per-plate representations  of  the  ossicles  in  situ,  are  somewhat 
diagrammatic,  but  they  are  almost  as  instructive  as  the  accu- 
rate photographs  of  Rudinger  of  our  own  day.  Those  of  the 
semi-circular  canals  remain  in  some  respects  unsurpassed. 

Saunders,  Van  der  Hoeven,  Alex.  Fischer,  Teole,  and  David 
Todd  (1806),  also  contributed  essentially  to  complete  our  knowl- 
edge of  the  anatomy  of  the  ear. 

Alexander  Monro1  (1797),  "Professor  of  Anatomy,  Medicine, 
and  Surgery  "  in  the  University  of  Edinburgh,  was  the  author 
of  a  monograph  on  the  organ  of  hearing  in  man  and  other  ani- 
mals. It  is  a  fine  specimen  of  typography.  In  his  preface  he 
states  that  Dr.  Camper  called  in  question  his  description'  of  the 
semi-circular  canal  in  whales,  and  that  Scarpa  said  that  some  of 
his  teachings  in  regard  to  the  human  ear  were  erroneous.  Pro- 
fessor Monro,  claims  to  have  been  the  first  anatomist  to  trace  the 
auditory  nerve  within  the  cochlea,  vestibule,  and  semi-circular 
canals.  He  quotes  from  Valsalva,  Winslow,  Cassebohm,  Haller, 
Cotunnius,  Meckel,  and  others,  to  show  that  none  of  these  anat- 
omists had  traced  nerves  into  the  cochlea.  Dr.  Monro  seems  to 
make  out  a  good  case  for  himself  as  against  Scarpa,  as  far  as  I 
have  been  able  to  determine,  and  to  be  entitled  to  the  credit  of 
having  traced  the  nerves  into  the  cochlea,  before  and  with  greater 
minuteness  than  Scarpa,  and  he  appears  to  have  been  correct  in 
his  comparative  anatomy. 

Sir  Everard  Home  (1800)  wrote  an  excellent,  and,  for  its  time, 
exact  account  of  the  membrana  tympani  in  a  paper  for  the  Royal 

'Three  treatises  on  the  Brain,  the  Eye,  and  the  Ear.     Edinburgh  and  London,  1797. 


PROGRESS   OF   OTOLOGY.  11 

Society.1  The  measurements  are  accurately  given,  but  Mr. 
Home  supposed  that  the  fibrous  layer  was  muscular.  He  seems 
to  have  been  a  comparative  anatomist  of  great  ability. 

Samuel  Thomas  Soemmering  (1806),  a  great  name  in  anatom- 
ical science,  contributed  to  otology  by  a  series  of  plates  of  the 
anatomy  of  the  ear,2  which  are  almost  as  well  worth  study  to- 
day as  they  were  seventy  years  ago. 

Henry  Jones  Shrapnell  (1832)  contributed  a  series  of  papers 
to  the  London  Medical  Gazette.*  He  described  the  membrana 
flaccida  of  the  drum-head,  its  nerves,  with  clearness  and  accu- 
racy. His  description  of  the  former  is  available  for  the  student 
of  the  present  time,  and  ShrapnelFs  membrane  is  probably  firmly 
fixed  in  the  nomenclature  of  the  anatomy  of  the  ear. 

Thomas  Buchanan  (1832),  of  Hull,  brought  out  a  monograph 
illustrative  of  the  anatomy  and  diseases  of  the  ear.  His  ideas 
as  to  the  importance  of  the  cerumen  produced  many  errors  in 
treatment,  from  which  the  profession  has  not  yet  fully  recov- 
ered. He  published  four  works  ;  the  title  of  the  last  one  illus- 
trates what  has  just  been  said  :  "  Physiological  Illustrations  of 
the  Organ  of  Hearing,  more  particularly  of  the  Secretion  of 
Cerumen,  and  its  Effects  in  rendering  Auditory  Perception  Acute 
and  Accurate."  4 

The  distinguished  English  surgeon,  T.  Wharton  Jones,  Esq. 
(1836-39),  contributed  to  a  great  cyclopaedia  an  article  on  the 
organ  of  hearing,  which  comprised  all  that  was  known  up  to 
that  time,  and  which  is  a  very  valuable  monograph  for  refer- 
ence.5 

We  are  now,  in  our  review  of  the  investigations  of  the  anat- 
omy of  the  ear,  down  nearly  to  our  own  time  ;  and  we  come  to 
the  familiar  names  of  Huschke,  Arnold,  Schlemn,  Johannes 
Miiller,  Breschet,  Boiinafont,  and  Toynbee  (1824-51). 

Huschke,  and  especially  Breschet,  examined  the  labyrinth 
more  thoroughly.  Breschet  called  attention  to  much  that  was 
incorrect  in  anatomical  nomenclature.  Bock,  Jacobson,  Arnold, 
Schlemn,  and  Miiller  greatly  increased  our  knowledge  of  the 
different  nerve-tracts.  The  anatomical  and  physiological  text- 
books of  Breschet,  J.  F.  Meckel,  Weber,  Cloquet,  and  others, 
added  much  to  the  common  stock  of  anatomical  knowledge. 

1  Philosophical  Transactions,  1800.     The  Croonian  Lecture. 

.    -  Samuelis  Thomae  Soemmering  :   Icones  Organi  Auditus  Humani.     Francof  urti  ad 
Mcenum,  1806. 

3  Vol.  x.,  1832. 

4  Mr.  Wilde  on  the  early  history  of  Aural  Surgery.     Dublin  Medical  Journal,  1844, 
p.  441. 

6  Cyclopaedia  of  Anatomy  and  Physiology.     Edited  by  Robert  B.  Todd. 


12  A   SKETCH   OF   THE 

These  authors  grouped  and  assimilated  facts  that  the  centuries 
had  produced,  and  added  not  a  few,  as  the  result  of  their  own 
labors.1 

Toynbee "  (1851)  investigated  anew  the  membrana  tympani. 
He  especially  added  to  our  knowledge  in  regard  to  the  fibrous 
layer,  and  described,  for  the  first  time,  the  dermoid  layer.  This 
paper  was  published  in  the  "Philosophical  Transactions."  It 
was  preceded  by  papers  in  the  "  Medico-Chirurgical  Transac- 
tions," on  the  pathological  anatomy  of  the  ear,  papers  which 
have  given  Toynbee  lasting  fame,  because  they  did  very  much 
to  place  otology  upon  as  sound  a  basis  in  pathology,  as  that  it 
had  obtained  in  anatomy,  by  the  labors  we  have  enumerated. 

Toynbee's  statements,  that  the  Eustachian  tube  was  usually 
a  closed  canal,  that  muscular  action  was  required  to  open  it,  and 
that  swallowing  was  a  simple  way  of  effecting  this,  led  to  Polit- 
zer's  method  of  inflating  the  ear,  of  the  value  of  which  procedure, 
more  will  be  said  in  our  review  of  the  progress  in  therapeutics. 

Von  Troltsch  (1856)  began  a  series  of  anatomical  investiga- 
tions which,  we  may  hope,  have  not  yet  ended.  His  contribu- 
tions relate  to  the  structure  of  the  membrana  tympani,  the 
muscles  of  the  Eustachian  tube,  and  the  pathological  anat- 
omy of  the  middle  ear.  He  described  two  peculiar  constant 
formations  on  the  inner  side  of  the  membrana  tympani,  (pockets) 
which  had  only  been  mentioned  by  Arnold,  as  folds  of  mucous 
membrane.  In  the  course  of  some  investigations  of  the  cavity 
of  the  tympanum  of  the  foetus,  he  also  found  that  it  was  filled 
with  a  proliferation  of  the  mucous  membrane  of  the  labyrinth 
wall,  which  forms  a  mucous  cushion  that  rapidly  lessens  in  size 
after  birth.  This  anatomical  fact,  explained  the  frequency  of 
inflammations  of  the  middle  ear  in  young  children. 

Gerlach s  (1858)  followed  Toynbee  in  the  investigation  of  the 
fibrous  layer  of  the  membrana  tympani,  and  showed  that  in  the 
extreme  periphery  the  circular  fibres  were  wanting. 

Magnus  (1860)  investigated  anew  the  articulations  of  the  os- 
sicula,  and  asserted  that  there  was  no  real  joint  between  the 
malleus  and  incus.  He  also  denied  the  voluntary  or  involuntary 
contraction  of  the  tensor  tympani  muscle. 

Politzer  and  Lucse  (1862)  published  the  results  of  experi- 
ments, which  were  supplementary  to  those  of  Miiller,  showing 
that  the  origin  of  a  certain  crackling  sound  in  the  ear  was  not 
in  the  tendon  of  the  tensor  tympani,  but  in  the  Eustachian  tube. 
Politzer  also  made  valuable  experiments  upon  intra-auricular 
pressure,  proving  that  in  the  Valsalvian  method  of  inflating 

1  Lincke  :  Band  I.,  p.  27.  *  Diseases  of  the  Ear.     English  edition. 

3Schwartze,  Archiv  fur  Ohreuheilkunde.     Bd.  L 


PROGRESS   OF   OTOLOGY.  13 

the  ear,  not  only  were  the  tympanic  cavity  and  the  membranes 
of  the  fenestrse  of  the  labyrinth  with  the  membrana  tympani, 
placed  under  an  abnormal  pressure,  but  also  the  contents  of  the 
labyrinth — the  labyrinthine  fluid,  the  membranous  labyrinth, 
and  the  termination  of  the  acoustic  nerve. 

Lucse '  showed  that  a  vibrating  tuning-fork  placed  on  the 
mastoid  process  set  the  membrana  tympani  and  ossicula  auditus 
in  vibrations  which  could  be  represented. 

Corti J  (1851),  an  Italian  anatomist,  reviewed  the  work  of  his 
countrymen  who  studied  the  cochlea  in  preceding  centuries, 
and  divided  the  lamina  spiralis  membranacea  into  two  different 
broad  zones — an  inner  one,  Zona  denticulata ;  and  an  outer, 
Zona  pectinata.  He  described  a  regular  arrangement  of  pillars 
or  rods  like  the  strings  of  a  miniature  harp,  parts  now  known  as 
Corti's  pillars,  and  for  some  time  supposed  to  contain  the  termi- 
nation of  the  acoustic  nerve. 

Kolliker,  Claudius,  Bottcher,  and  Deiters,  followed  Corti  in 
investigations  of  this  part,  which  will  be  fully  noticed  in  discuss- 
ing the  anatomy  of  the  internal  ear. 

Hyrtl  (1858),  an  anatomist  of  great  industry  and  reputation, 
made  an  important  discovery  of  the  frequency  of  a  thin  and  por- 
ous bony  covering  to  the  cavity  of  the  tympanum,  and  thus 
explained  how  readily,  in  certain  cases,  an  otitis  may  become  a 
meningitis. 

The  pathological  anatomy  of  the  ear,  which  may  be  said  to 
have  been  first  accurately  studied  by  Toynbee,  has  received  large 
additions  since  his  time  at  the  hands  of  German,  English,  and 
American  writers,  among  whom  are  Hinton,  Meniere,  Voltolini, 
Troltsch  and  Schwartze.  Many  contributions  upon  pathological 
subjects  have  been  made  of  late  to  the  various  otological  jour- 
nals. Moos  and  Steinbrugge,  especially  have  begun  to  furnish 
accounts  of  the  pathology  of  the  cochlea,  which  are  steps  toward 
the  clearing  up  of  a  dark  chapter  in  aural  pathology. 

The  chief  advances  in  aural  patholgy,  since  the  above  was 
written  are  in  the  investigation  of  mastoid  abscesses  and  their 
relation  to  diseases  of  the  brain.  The  connection  between  sup- 
purations of  the  tympanum  and  of  the  mastoid,  is  beginning  to 
be  more  clearly  understood.  The  surgeon  has  become  more 
anxious  to  secure  free  drainage  from  the  tympanum,  in  order  to 
prevent  transferrence  of  the  suppuration  to  the  cerebrum,  with 
its  inevitably  fatal  results.  Besides,  he  does  not  even  hesitate 
to  attack  the  brain  substance  itself  when  he  has  good  reason  to 
believe  that  pus  has  formed  in  it. 

1  Virchow's  Archiv.     Bd.  XXV.,  Hefte  3  nnd  4. 

!  A  Manual  of  Histology.     Strieker,  p.  1054  (Translation). 


14  A   SKETCH   OF   THE 

PROGRESS  IN  AURAL  THERAPEUTICS.— TEXT-BOOKS,  DISPENSARIES,  AND 

HOSPITALS. 

In  the  earlier  ages,  the  progress  in  the  treatment  of  the  ear 
by  no  means  kept  pace  with  the  advance  in  the  knowledge  of  its 
anatomy.  While  the  structure  of  the  organ  was  sufficiently  well 
understood  to  cause  the  investigation  of  its  diseases  to  be  both 
interesting  and  profitable,  the  treatment  was  crude  and  illogical, 
unworthy  of  the  knowledge  which  should  have  been  its  basis. 

Herodotus1  says  that  there  were  specialists  in  Egypt,  a  par- 
ticular physician  for  each  disease,  but  no  mention  is  made  of 
aurists.  "  The  art  of  medicine  is  thus  divided  amongst  them ; 
each  physician  applies  himself  to  one  disease  only,  and  not 
more.  All  places  abound  in  physicians  ;  some  physicians  are 
for  the  eyes,  others  for  the  head,  others  for  the  teeth,  others  for 
the  parts  about  the  belly,  and  others  for  internal  diseases." 

Although  Hippocrates  knew  very  little  about  the  anatomy  of 
the  ear,  he  speaks  at  some  length  of  the  causes  of  aural  disease. 
For  many  of  these,  he  must  have  drawn  upon  his  imagination. 
They  were  very  comprehensive,  and  may  properly  be  said  to  ex- 
plain almost  anything.  They  are  such  as  heat,  cold,  dryness, 
moisture,  the  blood,  mucus,  and  the  yellow  and  black  bile. 

Hippocrates  considered  internal  inflammation  of  the  ear  as 
essentially  an  inflammation  of  the  head.  He  described  pains  in 
the  ear  connected  with  high  fever  as  a  very  dangerous  disease, 
and  he  states  that  if  neither  pus  escaped  from  the  ear,  nor  blood 
from  the  nose,  the  death  of  the  patient  usually  occurred  from  the 
ninth  to  the  eleventh  day.  This  was  probably  the  disease  that  we 
now  name  acute  catarrh  of  the  middle  ear,  and  the  great  medical 
philosopher  was  certainly  right  in  calling  it  a  serious  one. 

Among  all  the  improper  remedies  which  Hippocrates  recom- 
mends to  be  dropped  into  the  ear,  there  is  one  good  one,  although 
it  is  a  very  simple  application,  which  is  often  thought  to  be  a  sug- 
gestion of  our  own  day ;  that  is,  the  instillation  of  warm  water. 
The  great  physician  advises  the  water  to  be  poured  in  by  means 
of  a  sponge.  If  this  simple,  but  often  efficacious  treatment  were 
universally  practised  in  cases  of  acute  inflammations  of  the  outer 
and  middle  ear,  it  would  alleviate  a  great  deal  of  suffering. 

Hippocrates  seems  to  have  had  an  eye  to  the  effect  upon  the 
patient's  mind,  to  use  no  harsher  language,  if  we  may  believe 
that  the  following  passage  was  not,  as  Lincke  insinuates,  interpo- 
lated : a  "If  any  person  has  a  pain  in  his  ear,  the  physician  should 
roll  a  bit  of  wool  about  his  finger,  and  then  pour  some  warm  oil 
into  the  ear,  and  then  taking  the  wool  in  the  hollow  of  his  hand, 

1  Herodotus,  translated  by  Gary.     Euterpe,  p.  125. 
1  Lincke's  Handbuch,  Bd.  II.,  p.  5. 


PROGRESS   OF   OTOLOGY.  15 

and  hold  it  before  the  ear,  in  order  to  make  the  patient  believe 
it  has  come  out  of  it.  In  order  that  the  deception  may  be  com- 
plete, the  wool  should  be  at  once  thrown  into  the  fire." 

Hippocrates  laid  considerable  stress  upon  certain  aural  symp- 
toms in  constitutional  disease.  For  example,  he  considered  the 
presence  of  sweet  ear-wax  as  a  bad  symptom,  while  that  of  the 
bitter  was  not.  He  noted  that  acute  aural  disease,  sometimes  led 
to  a  fatal  result  on  the  third 'day  after  its  occurrence.  This  indi- 
cates his  perfect  appreciation  of  the  serious  character  of  such  a 
form  of  disease.  He  says  that  deafness  following  a  fever  is 
sometimes  cured  by  nasal  hemorrhage  or  diarrhoea,  and  so  forth. 

Heraclides  of  Tarent,  advises  caustics  made  of  verdigris, 
copper  filings,  and  honey,  for  the  removal  of  granulations  aris- 
ing from  abscesses  in  the  ear,  and  for  hemorrhages  from  the 
ear,  the  juice  of  white  horehound,  quince,  and  gall-nuts  mixed 
with  vinegar.  Galen  quotes  much  from  Apollonius  in  regard  to 
remedies  for  various  affections  of  the  ear.  A  famous  remedy 
for  earache  was  burned  opium  and  castoreum.  Apollonius  rec- 
ommended the  oil  of  bitter  almonds  for  fleas  and  maggots  in 
the  ear.  He  removed  foreign  bodies  by  means  of  ear-spoons, 
little  hooks,  and  probes,  which  were  wound  about  with  wool  and 
dipped  in  turpentine.  Hardened  cerumen  he  softened  with  a 
solution  of  saltpetre  in  vinegar,  and  then  cleaned  the  ear  with 
lukewarm  water  or  oil. 

Asclepiades,  a  friend  of  Cicero,  recommended  instillations 
for  the  ear,  of  oil  in  which  three  or  four  cockroaches  or  an 
African  snail  were  cooked,  while  a  piece  of  henbane  in  oil  of 
roses,  or  woman's  milk,  is  to  be  afterward  added. 

Aulus  Cornelius  Celsus  (B.C  44-A.D.  19)  also  used  a  compo- 
site remedy  which  was  said  to  be  of  service  in  all  kinds  of  dis- 
eases of  the  ear.  It  was  made  of  cinnamon,  cassia,  blossoms  of 
bulrushes,  castoreum,  white  pepper,  ammonia,  myrrh,  and  saf- 
fron, as  well  as  of  various  other  agents.  These  substances  were 
all  rubbed  up  with  vinegar,  and  diluted  with  the  same  agent 
when  used.  Celsus,  in  his  treatise  "  De  Medicina,"  spoke  in 
some  detail  of  aural  disease.  He  was  perhaps  the  first  to  recom- 
mend vigorous  injections  of  water  in  order  to  remove  foreign 
bodies  from  the  ear,  although  this  proper  recommendation  car- 
ries less  weight  than  it  would  have  done  had  it  not  been  mingled 
with  a  great  deal  of  bad  advice,  which  shows  that  a  disposition 
to  use  the  simplest  means  for  a  desired  end,  is  not  always  con- 
nected with  great  learning.  Celsus  recommends  in  obstinate 
cases  of  a  foreign  body  in  the  ear,  that  the  patient  should  be 
laid  upon  a  table,  and  upon  the  side  of  the  affected  ear,  when 
the  surgeon  should  strike  with  a  hammer  upon  the  table,  in 


16  A   SKETCH   OF   THE 

order  to  dislodge  the  foreign  body  by  the  concussion.  Celsus  also 
recommends  plastic  operations  for  the  restoration  of  lost  or  dis- 
figured auricles,  unless  the  subjects  be  unhealthy  and  cachectic. 

Among  the  mass  of  writers  mentioned  by  Lincke,  as  being 
before1  Galen's  time,  Archigenes  seems  to  have  had  some  cor- 
rect notions.  He  practised  venesection  for  severe  pain  in  the 
ear,  and  employed  purgative  enemas,  warm  baths  to  the  ear, 
especially  by  means  of  a  sponge  dipped  in  hot  water.  He  warns 
against  the  use  of  cold  water.  He  also  has  his  method  of  re- 
moving a  foreign  body  from  the  ear,  and  recommends  a  vigorous 
shaking  of  the  affected  head.  A  child  is  to  be  seized  by  the 
feet  and  well  shaken,  while  adults  are  to  be  held  very  much  as 
Celsus  proposed  ;  that  is,  they  are  to  be  laid  on  a  table,  while 
the  leaf  of  it  nearest  the  head  is  to  be  repeatedly  opened  and 
shut  with  a  slam.  Archigenes,  like  other  ancient  authorities, 
however,  thinks  very  much  of  instillations  of  various  kinds  for 
the  relief  of  the  different  forms  of  deafness.  He  recommends 
speaking-tubes  to  the  deaf. 

Galen  (A.D.  130-201)  recognized  the  importance  of  the  ear,  in- 
asmuch as  it  lies  so  close  to  the  head.  Although  his  classifi- 
cations of  disease  are  very  minute,  we  do  not  learn  much  from 
his  writings,  except  the  value  of  agents  that  will  excite  the 
secretions  of  the  nose  and  mouth,  which  he  recommends  in  aural 
disease.  He  complains  of  the  empirical  practices  of  his  pre- 
decessors, in  ordering  now  cold  and  now  warm  remedies,  now 
sweet  and  now  sour  ones. 

He  also  tells  of  a  poor  patient  of  some  less  learned  or  less 
practical  man  than  himself,  who,  in  accordance  with  advice, 
used  black  pepper  as  a  local  means  of  treatment  for  an  inflamed 
ear,  and  whose  sufferings  were  so  much  augmented,  that  he 
came  near  hanging  himself.  Galen  objects  to  the  too  common 
use  of  opium,  which  seems  to  have  been  employed  very  much 
in  relieving  the  pain  of  aural  disease.  Tinnitus  aurium,  accord- 
ing to  Galen,  was  due  in  some  cases  to  exhalations  from  the 
stomach,  and  in  others  to  increased  sensitiveness  of  the  ears. 
Both  of  these  causes,  certainly  leave  much  to  be  wished  for  in 
the  way  of  exact  knowledge  as  to  the  nature  of  this  distressing 
symptom.  It  would  be  tedious  in  the  extreme  to  follow  Galen, 
through  his  classification  of  diseases  of  the  ear  and  remedies 
for  them.  Like  his  predecessors  and  contemporaries,  he  was 
not  willing  to  admit  that  there  were  some  diseases  for  which 
remedies  were  useless,  so  far  as  their  knowledge  went.  The 
aural  prescriptions  of  the  ancients  were  usually  extremely  com- 
posite and  correspondingly  dangerous. 

Galen  makes  some  very  sensible  remarks  about  the  various 


PROGRESS   OF   OTOLOGY.  17 

kinds  of  sounds  that  are  pleasant  or  otherwise  to  the  ear.  The 
soft  and  slow  tones  of  the  human  voice,  in  his  opinion,  are  much 
the  pleasantest  to  the  human  ear.  A  rough  and  quick  voice 
is  distressing.  Fine  ears  tolerate  only  a  weak,  soft  voice, 
diseased  ears,  only  a  very  geiltle  and  weak  tone,  sometimes 
even  absolute  silence.  If  Galen  had  lived  in  the  nineteenth 
century,  and  in  New  York  with  its  uneven  pavements,  boiler 
shops,  locomotive  whistles,  elevated  railways,  and  Wagner 
music,  he  might  have  added  largely  to  his  category  of  sounds 
unpleasant  to  tired  and  morbid  ears.  Galen's  classification  was 
a  subjective  one  ;  for  example  :  1,  Otalgia  ;  2,  hardness  of  hear- 
ing ;  3,  cophosis  ;  4,  paracusis ;  5,  paracousmata,  or  hallucina- 
tions of  hearing ;  but  it  was  not  without  value. 

For  earache  from  a  cold,  he  recommends  the  warming  method 
by  means  of  wolf's  milk  or  pepper  mixed  with  old  oil.  For 
"inflammatory  earache"  fatty  or  oily  substances  are  recom- 
mended, the  fat  of  geese  and  hens  ;  and  if  the  pain  be  very 
severe,  a  mixture  of  opium,  musk,  and  the  white  of  an  egg,  with 
or  without  the  addition  of  castoreum,  or  a  solution  of  opium  in 
thickly  cooked  juice  of  fruit.  All  these  substances  were  poured 
while  warm  into  the  ear. 

Dioscorides  and  Plinius,  recommend  a  host  of  remedies  for 
aural  disease.  Among  others,  the  latter  advises  the  excrement 
of  pigeons  and  the  ashes  of  horses'  dung. 

Cselius  Aurelianus,  a  successor  of  Galen,  stands  out  promi- 
nently from  the  absurd  theorizers  of  his  time,  in  his  clear  de- 
lineations of  pain  in  the  ear  and  his  sensible  remedies  for  it — 
leeches,  cups,  poultices,  mustard-plasters,  and  so  on. 

About  this  time  we  read  of  the  materia  medica  of  Marcellus, 
who  gives  us  a  glimpse  of  the  popular  remedies  of  the  day. 
Frog's  fat  is  recommended  for  pain  in  the  ear  ;  the  urine  of 
pigs,  of  children  and  men,  and  the  blood  of  young  chickens  for 
an  ulcer  in  the  ear ;  for  worms  in  the  organ,  the  saliva  of  a 
hungry  man,  and  so  forth.  We  see  a  great  deal  in  the  ancient 
literature,  concerning  worms  in  the  ear  ;  so  that  we  must  con- 
clude that  they  were  much  more  commonly  found  in  the  olden 
time  than  with  us.  This  was  probably  due  to  the  fact  that  cases 
of  neglected  suppuration  were  very  frequent,  and  that  living 
larvse  were  thus  often  developed. 

The  famous  surgeon  and  obstetrician,  Paulus  ^Egineta  (GOO 
A.D.),  who  flourished  in  the  seventh  century,  should  be  remem- 
bered as  a  contributor  to  the  surgery  of  otology.  He  expended 
much  energy  on  the  subject  of  foreign  bodies  in  the  ear,  a  field 
which  has  unfortunately  always  suffered  from  surgeons  over- 
anxious for  operations. 
2 


18  A   SKETCH   OF  THE 

Paulus  ^Egineta  made  a  good  classification  of  cases  of  closure 
of  the  external  auditory  canal :  1,  congenital ;  2,  from  ulcera- 
tion  ;  3,  superficial  or  deep.  He  gives  sound  advice  as  to  the 
removal  of  aural  polypi,  divides  deafness  into  congenital  and  ac- 
quired, and  seems  altogether  to'have  been  a  man  in  advance  of 
his  time.  His  surgical  writings  are  said  to  abound  in  novel  and 
ingenious  views.  He  suggested  the  operation  of  detachment  of 
the  auricle  for  the  removal  of  foreign  bodies  situated  in  the 
tympanic  cavity  or  deep  in  the  external  auditory  canal.  This 
operation  was  again  advised  by  Troltsch  and  was  performed 
(1871)  by  the  author  of  this  volume,  and  by  Orne  Green  (1881), 
and  Buck  (1882),  and  in  spite  of  theoretical  objections  urged 
against  it,  has  proved  itself  a  practical  operation  in  certain  cases. 
Hippocrates,  also,  is  said  to  have  recommended  this  procedure. 

Guido  Guidi  (1595)  about  this  time,  in  his  recapitulation  of  the 
works  of  Hippocrates,  Celsus,  Galen,  Paul  of  JE>gina,  and  others, 
gives  the  sensible  advice  to  keep  the  ear  uncovered,  and  the 
meatus  unstopped,  in  order,  as  he  says,  that  sound  may  enter  it 
properly  and  the  ear-wax  run  out  freely.  For  congestion  of  the 
ear,  he  advises  leeches  placed  in  the  nostrils. 

According  to  Lincke,  the  Arabians  got  their  knowledge  of 
otology,  whatever  it  was,  from  the  Greeks,  of  whom  Galen  was 
the  chief  authority  ;  so  that  we  can  only  add  a  few  more  absurd 
remedies  as  their  contribution  to  knowledge  :  for  deafness,  the 
brain  of  a  lion  mixed  with  oil  (the  brain,  not  the  lion)  is  advised 
by  Rhazes.  Serapion  advises  instillation  of  woman's  milk,  for 
the  cure  of  earache  in  children,  and  he  gives  the  important 
caution,  that  the  milk  must  be  that  of  a  woman  who  is  nursing 
a  female  infant,  if  it  be  a  boy,  who  is  affected. 

As  we  have  seen  in  noticing  the  progress  in  our  knowledge 
of  the  anatomy  of  the  ear,  the  centuries  from  Galen  to  Valsalva 
were  dark  ages  for  our  science.  Lincke  says:  "Otology  re- 
mained at  the  same  point  at  which  the  Grecian,  Roman,  and 
Arabian  physicians  had  left  it."  In  Lincke's  own  list  of  the 
progress  of  these  centuries  we  find  traces  of  ignorance  and  em- 
piricism only.  One  author  named  Gadesden  recommends  that, 
in  cases  of  inflammation  of  the  ear,  one  of  the  lower  classes  be 
hired  to  suck  out  all  the  morbid  material  of  the  ear,  by  means 
of  a  tube  placed  in  the  meatus  externus  ;  and  this  is  said  to  be 
a  cure  for  all  kinds  of  deafness,  not  even  excepting  that  from 
a  purulent  affection  of  the  organ.  Lincke  believes  that  Peter  de 
la  Cerlata  was  the  first  to  use  a  speculum  for  widening  the  audi- 
tory canal  for  purposes  of  inspection. ' 

"The  passage  quoted  to  sustain  this  view  is  "per  inspectionem  ad  solem  traJtendo 
aurem  et  ampliando  cum  speculo  aut  olio  instruments.^ 


PROGRESS   OF   OTOLOGY.  19 

Johannes  Arcularius  (1560)  gave  some  sensible  rules  for  the 
management  of  aural  disease.  He  declaimed,  for  instance, 
against  the  indiscriminate  practice  of  stuffing  the  ear  with  cot- 
ton ;  but  he  advised  an  extremely  peculiar  means  of  extracting 
a  foreign  body  from  the  ear.  '  The  head  of  a  lizard  is  to  be 
cut  off,  placed  in  the  affected  ear,  and  allowed  to  remain  there 
for  three  hours.  The  animal  is  then  to  be  removed,  when  the 
foreign  body  will  be  found  in  its  mouth. 

Alexander  Benedetti  (1560)  recommends,  as  a  remedy  for 
pain  in  the  ear,  the  semen  of  a  boar,  which  is  to  be  carefully 
taken  from  the  vagina  of  a  sow  before  she  has  dropped  it  upon 
the  ground.  This,  however,  is  the  suggestion  of  a  writer  on 
general  medicine,  and  not  on  otology. 

Gabriel  Fallopius  (1523-1562),  professor  of  anatomy,  surgery, 
and  botany  in  Ferrara  and  Padua  in  this  century,  seems  to  be 
entitled  to  the  honor  of  having  first  taught  that  a  discharge  of 
pus  from  the  ear  of  a  child  should  not  be  meddled  with  ;  for 
as  Fallopius  gravely  taught,  and  as  was  gravely  repeated  by 
some  of  his  legitimate  successors  for  more  than  three  hundred 
years,  this  discharge  of  pus  is  an  effort  of  nature  to  throw 
morbid  material  out  of  the  head  through  the  ear.  The  otorrhosa 
of  adults,  according  to  Fallopius,  is  also  a  discharge  from  the 
brain,  and  should  not  be  treated  by  astringents,  but  with  mild, 
cleansing  remedies.  He  used  an  aural  speculum,  and  employed 
sulphuric  acid  to  remove  polypi. 

The  great  revolutionist  in  medicine,  Paracelsus  (1490-1544), 
who  began  his  lectures  at  Basle,  by  burning  the  books  of  his 
predecessors,  and  who  afterward  boasted  of  having  read  no 
books  for  ten  years,  seems  to  have  paid  very  little  attention  to 
the  treatment  of  diseases  of  the  ear.  Deafness  he  considered  to 
be  incurable,  "for  what  nature  had  once  taken  away  a  physi- 
cian could  by  no  means  restore."  He  had,  however,  like  all  the 
ancients,  his  remedy  for  worms  in  the  ear,  and  one  for  each  kind 
of  worm. 

In  the  latter  half  of  the  sixteenth  century,  a  certain  Capivacci 
seems  to  have  deviated  a  little  from  the  errors  of  his  predeces- 
sors. He  speaks  with  more  precision  of  aural  disease.  He  de- 
scribes thickening,  ulcers,  and  cicatrices  of  the  membrana  tym- 
pani,  and  says  that  deafness  which  arises  from  an  affection  of 
the  nerve  or  labyrinth  is  incurable — a  declaration  which  his 
successors,  three  hundred  years  after  him,  find  true  of  a  large 
proportion  of  cases.  Capivacci  also  describes  a  method  of  mak- 
ing a  differential  diagnosis  between  the  diseases  of  the  per- 
ipheric,  and  of  the  central  parts  of  the  organ  of  hearing.  One 
end  of  an  iron  rod,  an  ell  in  length,  is  put  between  the  teeth  of 


20  A   SKETCH   OF  THE 

the  patient,  while  the  other  is  placed  upon  a  keyed  musical  in- 
strument, such  as  a  zither.  If  he  could  distinguish  the  tones 
produced  by  the  vibrations  of  the  keys  of  the  instrument,  his 
deafness  depended  upon  some  lesion  of  the  membrana  tympani ; 
if  not,  it  was  an  affection  of  the  nerve.  Here  we  see  glimpses 
of  deduction  from  the  anatomical  knowledge  of  the  time. 

In  the  seventeenth  century,  we  hear  of  De  Vigo  (1600),  body- 
surgeon  to  Pope  Julius  II.,  curing  his  Holiness  of  a  very  obsti- 
nate abscess  of  the  right  ear  by  means  of  a  mixture,  or  lini- 
ment, of  3  ij-  of  oil  of  eggs  with  3  iij.  of  oil  of  roses.  What  kind 
of  an  abscess  this  was,  or  where  it  was  situated,  Lincke  does 
not  tell  us.  De  Vigo  was  opposed  to  the  removal  of  foreign 
bodies  by  means  of  the  detachment  of  the  auricle,  because  this 
part  was  too  sensitive  for  an  operation,  and  quiet  natura  sagax 
raro  vel  nunquam  deficit  in  orsis  bonis  operationibus. 

Peter  Forest,  who  may  have  been  an  Englishman,  judging 
from  his  name,  but  who  practised  in  Rome  in  this  century,  to 
whose  works  Lincke  gives  no  definite  reference,  collected  fifteen 
cases  of  aural  disease  that  seem  to  have  been  carefully  observed. 
One  is  a  case  of  disease  of  the  ear,  ending  in  an  affection  of  the 
brain  and  death.  He  speaks  of  pain  in  the  ear  caused  by  the 
rays  of  the  sun,  and  he  tells  a  wonderful  story  of  a  female  deaf 
for  seven  years — so  deaf  that  she  could  not  hear  a  clock  strike — 
who,  being  advised  by  that  character  so  common  in  medical 
scenes,  an  old  woman,  to  put  some  musk  in  her  ear,  did  so,  and 
was  cured.  He  also  tells  how  his  teacher,  Gisbert  Horst,  the  di- 
rector of  a  hospital  in  Rome,  used  to  cure  deafness  with  water 
that  had  been  distilled  over  a  young  mouse  having  no  hair. 

We  trace  one  of  the  delusions  that  still  lingers  among  us — 
namely,  that  the  hearing  is  completely  destroyed  when  the 
membrana  tympani  is  broken — to  a  writer  named  Hercules  Sas- 
sonia,  who  lived  in  this  century.  He  also  had  the  peculiar  no- 
tion that  patients  always  spoke  in  a  low  tone  when  the  disease 
of  the  ear  was  seated  in  the  auditory  nerve,  because  the  nerve 
supplying  the  tongue,  a  branch  of  the  fifth,  was  at  the  same  time 
affected.  In  deafness  arising  from  venereal  disease,  blisters 
behind  the  ear  and  a  mixture  of  oil  of  guaiacum  and  hydro- 
chloric acid  as  a  local  application,  of  which  the  patient  drank  a 
little,  were  highly  spoken  of. 

The  great  Frenchman,  the  father  of  modern  surgery,  Am- 
broise  Pare  (1510-1590),  figures  in  otological  history  as  the  first 
one  to  employ  a  syringe  for  cleansing  the  ear.  He  also  recom- 
mended artificial  auricles  of  papier  mache  or  leather. 

It  was  in  the  latter  half  of  the  sixteenth  century,  that  zeal 
for  the  education  of  deaf  mutes  first  began  to  exhibit  itself.  It 


PROGRESS   OF   OTOLOGY.  21 

is  probable  that  the  Greeks  and  Romans  made  no  efforts  in  this 
direction,  for  they  had  decided  that  nothing  reached  the  intel- 
lect except  through  the  hearing,  that  there  could  be  no  intel- 
lectual process  without  hearing,  and  they  had  given  over  deaf 
mutes  as  they  did  idiots  and  insane  people.  Although  isolated 
instances  had  been  noted  of  instruction  for  the  deaf  mute — in- 
stances like  that  of  the  dumb  youth  taught  by  one  of  the  early 
English  bishops,  St.  John  of  Beverley — they  were  generally  con- 
sidered as  supernatural  occurrences.  Rodolphus  Agricola,  of 
Groningen,  born  in  1442,  stated  that  he  knew  of  a  deaf  mute 
who  had  been  taught  to  write  and  note  down  his  thoughts. 
Fifty  years  afterward  this  was  denied,  on  the  ground  that  no  one 
could  be  instructed  who  could  not  be  taught  through  the  ear. 

Jerome  Cardan,  who  was  born  in  Pavia  in  1501,  is  said  to  be 
the  man  who  showed  that  written  characters  and  ideas  may  be 
connected  together  without  the  use  of  sounds.  This  fact,  now 
universally  accepted  and  assumed,  was  a  new  idea  in  the  six- 
teenth century.  Benedictine  monks  in  Spain,  first  put  Cardan's 
principles  into  practice,  and  from  that  country  they  gradually 
spread  throughout  the  civilized  world,  until  now  in  every  nation 
the  deaf  mute,  like  his  more  fortunate  fellows,  has  an  oppor- 
tunity for  education.  The  reader  has  seen  what  a  great  debt  the 
scientific  world  owes  to  Italy,  and  nowhere  is  this  more  apparent 
that  in  what  was  promulgated  by  Cardan. ' 

Caspar  Tagliacottzi  (1597),  of  Bologna,  who  did  so  much  for 
plastic  surgery,  did  not  neglect  the  ear,  but  attempted  to  restore 
the  auricle  by  taking  integument  from  the  adjacent  skin.  He 
relates  one  case,  that  of  a  Benedictine  monk,  for  which  he  had 
done  this  with  success. 

Although  the  aural  speculum  had  been  used  a  hundred  years 
before,  we  find  a  certain  Johami  Hartman  (1(390),  a  disciple  of 
Paracelsus,  very  unwilling  to  use  it  ;  for  he  advised  the  detec- 
tion of  inspissated  cerumen  by  the  following  simple  method. 
He  placed  a  curved  silver  tube  into  the  ear  and  blew  through  it. 
If  the  patient  felt  the  breath  to  be  cold,  the  deafness  did  not 
proceed  from  impaction  of  wax.  In  our  day  the  detail  of  this 
method  is  sometimes  simplified  without  altering  the  principle  ; 
that  is  to  say,  a  probe  is  used  to  see  if  wax  is  in  the  ear.  Through 
all  this  century,  the  seventeenth,  there  are  numerous  volumes 
on  the  treatment  of  the  ear,  but  they  all  tread  through  the  bar- 
ren waste  of  drops  and  decoctions,  theories,  nomenclatures,  and 
rank  empiricism. 

Lusitanus  gives  an  amusing  explanation  of  the  practice  of 


1  Encyclopaedia  Britannica,  Vol.  VII.     Article,  Deaf  and  Dumb. 


22  A   SKETCH   OF  THE 

cutting  off  the  ears  of  thieves.  He  said  that  such  treatment 
rendered  them  incapable  of  propagating  their  kind,  and  hence  no 
more  thieves  could  be  born  of  them.  He  founded  this  opinion 
on  the  statement  of  Hippocrates  that  the  division  of  the  veins 
behind  the  ear,  rendered  a  man  sterile,  because  the  semen,  which 
was  generated  in  the  head,  could  no  longer  pass  down  to  the 
genitals. 

Johann  Baptista  van  Helmont,  evidently  a  Belgian,  casts 
away  the  theory  that  had  so  long  prevailed,  of  deafness  being 
caused  by  ascending  exhalations,  and  clears  up  the  whole  matter 
by  ascribing  it  to  the  work  of  the  devil,  or  other  evil  spirits. 

Marcus  Banze  (1640)  gives  us  the  first  idea  of  an  artificial 
membrana  tympani,  by  proposing  to  place  a  tube  of  ivory,  the 
end  of  which  is  covered  by  a  bit  of  pig's  bladder,  in  the  auditory 
canal,  as  a  protection  to  the  exposed  ear,  when  the  membrana 
tympani  was  lost  by  ulceration.  He  did  not,  however,  propose 
this  as  an  improvement  to  the  hearing  power. 

The  renowned  surgeon,  Fabricius  of  Hilden  (1646),  or  Fabri- 
cius  Hildanus,  so  called  to  distinguish  him  from  Fabricius  of 
Acquapendente,  contributed  somewhat  to  the  surgery  of  the  ear. 
He  invented  an  instrument  for  extracting  foreign  bodies  from 
the  ear,  as,  indeed,  every  surgeon  of  eminence  seems  to  have 
thought  it  his  duty  to  do.  This  instrument  consisted  of  a  large 
tube  which  was  introduced  into  the  auditory  canal  down  to  the 
foreign  body  ;  of  a  smaller  tube  with  a  toothed  extremity  placed 
inside  of  this,  and  in  this  again  a  trephine,  which  was  turned 
in  an  opposite  direction  from  the  second  tube  containing  the 
teeth.  He  also  wrote  of  the  removal  of  aural  polypi. 

In  the  latter  half  of  the  seventeenth  century,  Thomas  Willis ' 
attempted  to  prove,  by  experiments  on  animals,  that  total  deaf- 
ness does  not  ensue  when  the  membrana  tympani  is  destroyed. 
He  also  made  some  interesting  observations  on  deaf  persons 
who  only  heard  in  the  midst  of  a  noise.  The  most  interesting 
one  is  that  of  a  woman  who  could  only  hear  her  husband  when 
a  servant  was  beating  a  drum.  The  conversations  in  that 
family  were  probably  not  very  protracted.  This  kind  of  im- 
pairment of  hearing,  which  was  called  paracusis  Willisiana, 
was  referred  by  its  describer  to  a  relaxation  of  the  membrana 
tympani,  the  normal  tension  being  restored  by  the  noise,  or 
vibrations  of  the  atmosphere.  These  observations  will  be  found 
in  full  in  the  latter  part  of  this  book. 

Du  Verney  (1683),  known  by  his  labors  in  the  anatomy  of  the 


1  Opera  Omnia  Amstersedamia  apud  Henricum   Wetsteinum.     Pars  physiologica. 
Cap.  xiv. ,  p.  67. 


PROGRESS   OF   OTOLOGY.  23 

ear,  and  his  work  on  its  diseases,  contributed  very  little  to  sound 
knowledge,  although  he  made  an  attempt  to  arrange  the  dis- 
eases in  accordance  with  the  anatomy.  He  however,  disputed 
the  generally  accepted  opinion  that  a  discharge  of  pus  from  the 
ear  came  from  the  brain,  and  showed  that  the  meatus  audi- 
torius  internus  was  closed  by  the  auditory  nerve,  a*nd  that  the 
pus  must  pass  through  the  cochlea  and  the  f enestra  ovalis  and 
fenestra  rotunda,  before  it  could  get  into  the  external  auditory 
canal. 

Du  Verney  modified  the  suggestion  of  Hippocrates  to  get  at  a 
foreign  body  not  otherwise  easily  removed,  by  making  an  open- 
ing behind  the  ear,  and  recommended  that  the  incision  be  made 
upon  the  upper  side,  because  the  vessels  are  smaller  in  this  po- 
sition. He  thus  anticipates  Von  Troltsch,  who  made  the  same 
modification  of  the  original  suggestion  nearly  two  hundred 
years  later.1 

In  the  works  upon  the  ear  that  appear  in  this  century,  we  still 
continue  to  hear  much  of  the  presence  of  worms,  or  living  lar- 
vae— a  state  of  things,  however  common  among  the  ancients, 
that  is  now  very  rare,  because  suppurating  ears  are  usually 
cleansed.  The  disgusting  and  magical  ear-drops  of  the  early 
and  dark  ages  are  still  used  in  this  latter  part  of  the  seventeenth 
century.  Thus  one  writer  records,  that  a  Capuchin  monk  mixed 
the  urine  of  a  female  donkey,  that  had  brought  forth  but  once, 
with  that  of  a  male  hare,  of  a  wolf,  or  in  case  of  the  absence 
of  the  latter,  of  an  entirely  white  goat,  warmed  it,  and  adding  a 
little  oil  of  caraway,  used  it  as  drops  for  the  ear.  Urine  of  the 
various  animals  figures  largely  among  the  ear-drops  of  the  pe- 
riod. Paullini,  one  of  the  writers  of  the  day,  is  in  doubt,  how- 
ever, whether  it  is  proper  that  women  should  use  the  renal 
secretion  of  dogs  as  a  remedy  for  deafness. 

We  begin  to  hear  more  in  the  latter  part  of  the  seventeenth 
century  of  the  education  of  the  deaf  and  dumb,  but  it  is  mingled 
with  much  that  is  absurd  in  attempts  at  treatment.  The  great 
error  was  then  made,  as  it  often  is  now,  of  supposing  that  the 
diseases  of  the  ear  which  produced  deaf-muteism,  were  of  a  dif- 
ferent nature  from  those  which  in  the  adult  cause  deafness  only. 

John  Wallis,  an  Englishman,  was  perhaps  the  first  to  in- 
struct a  deaf-mute  to  speak — and  he  instructed  him  so  that  he 
spoke  very  well.  The  case  was  one  of  acquired  deaf-muteism, 
the  patient  having  lost  his  hearing  at  eight  years  of  age  ;  but 
he  became  able  to  read  the  Bible  aloud,  and  to  converse  with 
some  fluency. 


Diseases  of  the  Ear.     English  translation,  p.  488. 


24  A   SKETCH   OF   THE 

Lincke  begins  his  account  of  the  progress  of  otology  in  the 
eighteenth  century,  with  the  lament  that  it  did  not  keep  pace 
with  the  anatomical  investigations  of  the  ear,  which  had  been 
brought  to  such  a  high  point  by  the  labors  of  Valsalva,  Casse- 
bohm,  Cotugno,  and  Scarpa,  and  he  says  that  otology  would 
have  advaifced  very  much  faster,  had  Antoine  Marie  Valsalva 
devoted  himself  more  to  its  prosecution.  But  Valsalva  did 
much  to  give  us  correct  notions  in  regard  to  the  diseases  of  the 
ear.  He  proved  that  there  were  cases  where  the  membrana 
tympani  had  been  restored.  He  showed  that  the  hearing  power 
is  merely  impaired,  not  lost,  by  a  perforation  of  the  membrana 
tympani.  He  recognized  anchylosis  of  the  base  of  the  stapes  as 
a  cause  of  deafness.  He  gave  us  the  Valsalvian  experiment — 
the  mode  of  forcing  air  through  the  Eustachian  tube  by  a  forced 
expiration,  with  the  mouth  and  nostrils  closed — and  he  advises  it 
as  the  best  means  of  cleansing  the  middle  ear  from  pus.  He 
proved  that  the  cavity  of  the  tympanum  is  connected  to  the  cells 
of  the  mastoid  process,  by  a  case  in  which  he  injected  the  former 
through  a  fistulous  opening  in  the  latter.1  He  also  showed  that 
closure  of  the  Eustachian  tube  is  often  a  cause  of  impairment 
of  hearing.  This  is  certainly  a  refreshing  catalogue  after  we 
have  been  wading  through  the  disgusting  empiricism  of  the 
centuries  before. 

He  reports  the  case  of  a  man  who  suffered  from  a  nasal  poly- 
pus, which  gradually  by  its  growth  closed  the  pharyngeal  orifice 
of  the  Eustachian  tube,  and  caused  deafness.  He  also  relates 
the  case  of  a  man,  who  suddenly  lost  his  hearing  while  suffering 
from  a  pharyngeal  ulcer  in  the  neighborhood  of  the  tube,  when 
a  tent  was  placed  in  the  ulcer,  but  who  immediately  regained  it 
when  the  tent  was  removed.  Valsalva's  century  is,  however, 
also  cursed  with  theoretic  treatises  on  aural  disease,  such  as 
that  of  one  Frederich  Hoffmann,  who  goes  on,  in  the  good  old 
way,  with  instillations  of  wonderfully  compounded  ear-drops. 
Lincke  mentions  numerous  inaugural  dissertations  of  this  time, 
but  they  relate  chiefly  to  cases  that  were  not  properly  understood 
by  the  reporters  of  them ;  and  these  authors,  as  well  as  their 
theses,  are  deservedly  forgotten. 

J.  L.  Petit  (1774),  in  a  work  upon  surgical  diseases,  reports 
many  interesting  cases  of  caries  of  the  temporal  bone.  In  one 
case  of  suppuration  in  the  ear,  with  caries  of  the  mastoid,  he  ad- 
vised that  this  part  should  be  cut  down  upon  and  trepanned. 


1  As  I  have  elsewhere  shown,  this  case  was  for  a  long  time  supposed  to  be  one  of 
perforation  of  the  mastoid  by  a  surgical  operation.  See  chapter  on  the  diseases  of  the 
mastoid. 


PROGRESS   OF   OTOLOGY.  25 

His  advice  was  not  followed,  and  the  patient  died.  He  also  re- 
lates cases  where  this  operation  was  successfully  performed, 
and  he  must  therefore  be  considered  as  the  originator  of  this 
valuable  means  of  treatment. ' 

We  then  come  to  the  famous  postmaster  of  Versailles,  Guyot 
(1724),  who  first  injected  the  Eustachian  tube.  His  own  hearing 
was  impaired,  and  in  order  to  relieve  it  he  introduced  an  angu- 
lar tube  of  tin  through  the  mouth,  opposite  (gegen),  not  into,  the 
Eustachian  tube.  The  distal  extremity  of  this  instrument  was 
attached  to  a  leathern  tube.  This  was  connected  to  the  reser- 
voir of  two  small  pumps,  which  were  moved  by  two  cranks  and 
a  wheel  fastened  in  machinery,  by  means  of  which  he  forced 
fluid  through  a  curved  pewter  tube,  placed  behind  the  uvula, 
into,  or  about,  the  mouth  of  his  Eustachian  tube,  and  relieved 
the  impairment  of  hearing. 

Beck2  (1735),  who  quotes  from  the  "Hist,  de  1'Acad.  des 
Sciences,"  thinks  that  Guyot  washed  out  the  mouth  of  the  Eusta- 
chian tube.  We  now  know,  thaf  even  this  is  a  very  valuable 
means  of  treatment.  I  regret  very  much  that  I  cannot  find 
Guyot's  original  report  to  the  French  Academy,  in  any  of  our 
New  York  libraries. 

Archibald  Cleland  (1741),  an  English  army  surgeon,  advised 
injections  of  the  Eustachian  tube  with  warm  water,  by  means  of 
a  syringe  joined  to  a  flexible  silver  tube  introduced  through  the 
nose  into  the  oval  opening  of  the  duct,  at  the  posterior  opening  of 
the  nares,  toward  the  arch  of  the  palate.  A  sheep's  ureter  was 
fastened  to  the  silver  tube,  to  the  other  end  of  which  the  syringe 
was  fastened.  His  contemporaries  seem  to  have  paid  little 
attention  to  his  suggestions,  for  Van  Swieten  recommends 
catheterization  of  the  tubes  through  the  mouth  as  a  possible 
operation.  Wilde  attempts  to  claim  the  use  of  the  catheter  as  a 
British  discovery.  He  makes  Guyot  a  mere  suggester  of  the 
operation  of  catheterization,  but  I  think  the  evidence  is  in  favor 
of  the  French  postmaster.  Cleland  also  used  probes  of  the  same 
size  of  the  catheter  to  explore  the  tube.  He  does  not  allude  to 
Guyot's  suggestions  to  the  French  Academy,  but,  unfortunately 
for  poor  human  nature,  this  is  by  no  means  proof  that  he  did  not 
know  of  them.  Certain  it  is,  however,  as  Wilde  states,  that  the 
English  surgeon  was  the  first  one  to  introduce  the  catheter 
through  the  nose,  the  only  proper  way  of  performing  the  opera- 
tion ;  and  he  says  that  Guyot  never  practised  the  operation 

1  For  a  full  account  of  the  operations  on  the  mastoid,  see  the  appropriate  chapter 
in  this  work. 

2  Die  Krankheiten  des  Gehoerorganes,  1827,  p.  21. 


26  A   SKETCH   OF   THE 

which  he  recommended,  and  that  it  was  on  this  ground  rejected 
by  the  French  Academy,  as  "he  wanted  the  recommendation  of 
facts  to  support  and  enforce  it." 

Archibald  Cleland  still  farther  advanced  the  science  of  otol- 
ogy by  introducing  a  three-inch  convex  lens,  with  a  handle,  as 
a  means  of  examining  the  ear.  The  ear  was  illuminated  by  a 
waxlight  attached  to  the  lens. 

Julian  Busson  (1748)  proposed,  in  rather  an  undecided  way, 
to  perforate  the  membrana  tympani,  in  order  to  remove  collec- 
tions of  pus  from  behind  it ;  but,  as  this  was  a  very  dangerous 
operation,  he  advised  the  inhalation  of  vapors  through  the 
mouth  and  nose,  and  then  that  they  be  forced  into  the  Eusta- 
chian  tube  by  means  of  Valsalva's  method,  as  he  thought  that 
the  pus  might  thus  be  driven  out  of  the  middle  ear. 

Jonathan  Wathan  (1755),  an  English  author,  reported  cases 
of  restoration  of  hearing  by  means  of  catheterization  of  the 
tube  through  the  nose.  His  papier  is  in  the  "  Philosophical  Trans- 
actions of  the  Royal  Society."*  He  seems  not  to  have  known  of 
Cleland's  labors  in  the  same  direction. 

The  surgeons,  after  the  seemingly  complete  failure  of  phy- 
sicians to  successfully  treat  diseases  of  the  ear,  animated  by  the 
invention  of  the  Eustachian  catheter  and  Petit's  operation  for 
perforation  of  the  mastoid,  seem  to  have  been  exceedingly  ac- 
tive in  otology  during  the  latter  half  of  the  eighteenth  century. 
Antoine  Petit,  as  well  as  Cleland,  recommended  the  use  of  an 
instrument  through  the  nose  instead  of  through  the  mouth,  as 
proposed  by  Guyot,  and  injections  through  the  tube  are  every- 
where recommended  in  their  writings. 

The  successful  cases  which  were  reported  about  this  time 
were  usually  among  young  persons.  It  is  probable  that  the  use 
of  the  Eustachian  catheter  fell  into  disrepute,  because  it  was 
used  in  chronic  cases  in  which  the  prognosis  should  have  been 
pronounced  bad  or  hopeless  from  the  beginning.  The  want  of 
success  in  such  cases  must  have  been  disheartening.  It  con- 
tributed much  to  the  opprobrium  attached  to  the  practice  of 
aural  surgery,  which  exists  in  our  own  day.  The  necessity  for 
greater  exactness  in  the  diagnosis  and  course  of  disease,  exists 
now  as  then.  If  we  achieve  it,  otology  will  be  on  as  sure  a  foun- 
dation as  any  part  of  our  science  and  art. 

One  very  careful  soul,  who  seems  to  have  been  in  great  horror 
of  the  operation,  proposed  that  patients  upon  whom  the  catheter 
was  to  be  used,  should  have  the  hairs  of  the  nostrils  removed, 
and  that  lukewarm  milk,  or  a  linseed-meal  mixture,  or  the  like, 
should  be  drawn  into  the  nostrils  a  day  before  the  instrument 
was  introduced,  so  as  to  make  the  parts  more  pliable. 


PROGRESS   OF    OTOLOGY.  27 

The  operation  of  perforation  or  trephining  the  mastoid  process 
also  fell  into  great  disrepute,  because  a  Danish  surgeon,  Berger 
(1792),  caused  it  to  be  performed  upon  himself,  and  very  im- 
properly, for  "  deafness  which  had  been  years  in  occurring,  and 
which  was  accompanied  by  vertigo,  headache,  and  noise  in  both 
ears."  Meningitis  resulted,  and  the  patient  died  in  a  few  days. 
This  put  a  stop  to  the  performance  of  this  very  useful  and  neces- 
sary operation,  until  it  was  lately  revived,  chiefly  through  the 
efforts  of  German  and  American  surgeons. 

Everard  Home  '  (1800),  by  his  writings,  suggested  to  Sir  Ast- 
ley  Cooper  the  operation  of  perforation  of  the  membrana  tym- 
pani,  which  the  great  English  surgeon  performed  successfully 
in  four  cases.  The  history  of  the  rise  and  fall  and  revival,  of 
this  operation  will  be  found  in  the  chapter  on  chronic  non-sup- 
puration of  the  middle  ear. 

John  Cunningham  Saunders  Q  wrote  a  work  on  the  ear,  its 
anatomy  and  diseases,  which  went  through  several  editions  in 
England  and  one  in  America.  It  is  a  brief  but  scientific  trea- 
tise, and  far  beyond  its  predecessors  in  value.  It  is  character- 
ized by  simplicity,  and  is  without  the  absurdities  of  the  older 
text-books.  It  is  deficient  in  descriptions  of  the  methods  of 
examining  the  drum-head,  and  teaches  the  erroneous  doctrine 
that  it  is  proper  to  probe  a  membrana  tympani  to  see  if  it  be  in- 
tact. It  should  be  remembered  that  Saunders  advised  paracen- 
tesis  of  the  membrana  tympani  in  cases  of  acute  suppuration  of 
the  tympanum — an  operation  that  was  revived  by  Schwartze  a 
few  years  ago. 

He  says3:  "But  let  it  be  admitted  that  the  tympanum  has 
suppurated,  ought  the  membrana  tympani  to  be  abandoned  to  a 
casual  ulceration,  or  is  it  better  to  open  it  by  art  ?  I  am  inclined 
to  prefer  the  latter,  and  if  I  can  be  assured,  by  any  symptom, 
that  suppuration  has  taken^place,  I  should  not  hesitate  to  make 
a  small  perforation  of  the  membrana  tympani,  and  to  repeat  it, 
if  necessary,  taking,  at  the  same  time,  every  precaution  to  sup- 
press the  fresh  collection  of  matter.'' 

Saunders  speaks  wisely  against  the  objections  made  to  check- 
ing a  purulent  discharge  from  the  ears,  and  shows  that  disease 
of  the  brain  is  very  apt  to  follow  a  neglected  chronic  suppura- 
tion, and  he  gives  some  interesting  illustrative  cases.  The  book 
is  very  deficient  in  its  treatment  of  the  Eustachian  tube  and 
middle  ear.  Thus  early  do  we  find,  in  spite  of  Cleland's  and 

1  Philosophical  Transactions,  1800. 

2  The  Anatomy  of  the  Human  Ear,  etc.     Edited  by  Wm.  Price,  M.D.,  Philadel- 
phia, 1827. 

3Loc.  cit.,  p.  59. 


28  A   SKETCH   OF   THE 

Wathan's  teachings,  the  English  prejudice  against  the  use  of 
the  catheter,  a  prejudice  which  has  only  lately  been  overcome. 

Saunders  was  the  first  to  establish  an  infirmary  for  the  treat- 
ment of  diseases  of  the  ear.  It  was  also  an  eye  infirmary,  and 
was  opened  in  March,  1805.  At  a  later  date  it  was  limited  to 
the  treatment  of  the  diseases  of  the  eye.  In  1816  John  Harrison 
Curtis  established  the  "  Royal  Dispensary  for  Diseases  of  the 
Ear,"  in  London.  The  work  of  Curtis '  adds  nothing  to  our 
knowledge,  being  a  feeble  imitation  of  the  book  by  Saunders. 

J.  A.  Saissy  (1819),  of  Lyons,  devoted  the  last  twelve  years 
of  his  life  to  the  study  of  aural  disease.  He  published  a  work 
on  the  ear,  which  attained  the  honor  of  a  place  in  the  "  Diction- 
naire  des  Sciences  Medicales."  This  work  was  translated  into 
English  by  Nathan  R.  Smith,  the  celebrated  American  surgeon.2 

I.  M.  G.  Itard  (1821),  Physician  to  the  Royal  Deaf  and  Dumb 
Institution  in  Paris,  also  publishes  a  treatise,  which  was  trans- 
lated into  German,3  and  which  did  much  in  the  pioneer  work  of 
clearing  up  the  undergrowth  of  centuries  of  neglect. 

Then  followed  Deleau,  on  the  diseases  of  the  middle  ear  and 
on  perforation  of  the  membrana  tympani,  an  operation  for  which 
he  claimed  more  than  it  deserved. 

Thomas  Buchanan  (1823),  of  Hull,  published  a  work  on  the 
ear,  which  is  highly  spoken  of  by  Sir  William  Wilde,  especially 
as  to  his  remarks  upon  catheterization  of  the  Eustachian  tube 
and  puncturing  the  membrana  tympani.  He  had,  however,  fal- 
lacious views  with  regard  to  the  physiology  and  diseases  of  the 
external  auditory  canal. 

Karl  Joseph  Beck  (1827),  of  Freiburg,  published  a  "Handbook 
of  the  Diseases  of  the  Ear." 4  It  is  a  succinct  and  carefully  writ- 
ten compendium  of  what  was  then  known  in  this  department  of 
science,  and  has  a  very  good  bibliography,  with  the  exception 
that  the  names  of  English  authors  ar^e  very  often  misspelled. 

Wilhelm  Kramer  (1833),  of  Berlin,  an  author  who  died  in  1874 
at  a  ripe  old  age,  brought  out  a  work  which  was  animated  by  the 
true  scientific  spirit,  and  which  greatly  simplified  the  practice 
of  otology.  After  this  he  published  a  number  of  volumes.  He 
introduced  a  valvular-handled  speculum,  that  was  an  improve- 
ment upon  the  very  clumsy  ones  hitherto  in  use.  He  also  gave 
us  the  air-press,  by  which  air  or  vapors  could  be  introduced 
through  the  Eustachian  tube  into  the  middle  ear. 

1  A  Treatise  on  the  Physiology  and  Diseases  of  the  Ear,  by  John  Harrison  Curtis, 
Esq.  Third  edition.  London,  1823. 

5  An  Essay  on  the  Diseases  of  the  Internal  Ear.     Baltimore,  1829. 

3  Die  Krankheiten  des  Ohres  und  des  Gehors. 

4  Die  Krankheiten  des  Gehoerorganes.     Heidelberg  und  Leipzig,  1827. 


PROGRESS   OF   OTOLOGY.  29 

In  discussing  the  practices  of  his  predecessors,  the  intoler- 
ance of  Kramer's  spirit  is  seen— an  intolerance  which  is  pain- 
fully manifest  in  his  later  works.1  In  1860  he  speaks  of  the 
writings  of  Hinton  of  London — a  writer  whom,  I  am  sure,  all 
my  readers  will  learn  to  respect — "  as  in  every  respect  unimpor- 
tant," while  Toynbee's  pathological  investigations,  to  which 
science  is  so  much  indebted,  are  actually  treated  with  sneers. 
In  1865,  Kramer  published  a  monograph,3  which  was  essentially 
a  review  in  a  very  unfriendly  spirit  of  the  labors  of  Toynbee, 
Wilde,  Troltsch,  Erhard,  Voltolini,  and  others,  of  whose  writ- 
ings I  shall  soon  speak.  What  good  work  Dr.  Kramer  actually 
did  for  otology  in  his  younger  days,  was  overshadowed  by  his 
subsequent  writings.  In  spite  of  what  I  am  almost  inclined  to 
call  common  sense,  he  persisted  in  rejecting  the  modern  method 
of  investigation,  as  well  as  the  results  of  examinations  of  ears 
removed  from  persons  who  have  been  deaf.  He  still  continued 
to  use  the  handled  bi-valved  speculum,  with  sunlight  as  the 
only  source  of  illumination,  and  on  cloudy  days  sent  away 
patients  without  examination  up  to  his  last  days  of  practice; 
and  because  Toynbee  made  post-mortem  examinations  of  many 
ears  of  persons  whom  he  had  not  seen  during  life,  Kramer  re- 
jected all  pathological  investigations,  except  experiments  con- 
ducted upon  a  dead  body  or  a  glass  model.  He  described  Politzer's 
method  of  inflating  the  middle  .ear  "  as  a  miserable  resort  in 
cases  of  necessity,  the  employment  of  which,  all  pompous  com- 
mendations to  the  contrary  notwithstanding,  stamps  him  who 
uses  it  with  want  of  skill  in  the  introduction  of  the  catheter." 
Again  he  called  Toynbee,  in  his  work  published  in  1867,3  and  this 
after  Toynbee  had  lost  his  life  in  experiments  as  to  the  effect  of 
chloroform  and  hydrocyanic  acid,  *'a  wretched  aural  surgeon." 
"Ein  miserabler  Ohren-arzt."  These  are  fair  specimens  of  Dr. 
Kramer's  style  in  dealing  with  an  opponent,  with  any  one  who 
claims  to  have  accomplished  anything  for  aural  pathology  and 
therapeutics  in  any  other  way  than  by  the  employment  of  his 
catheters,  his  bougies,  and  his  valvular-handled  speculum. 

Yet  Kramer  did  much  for  the  advance  of  otological  science. 
If  he  had  possessed  an  unprejudiced  and  receptive  spirit,  he 
would  have  accomplished  much  more.  The  author  well  remem- 
bers him  in  his  pleasant  consulting  room  in  Berlin,  in  1863,  dis- 
dainfully declining  to  use  the  simple  method  of  examination  just 
recommended  by  Troltsch,  but  sending  away  his  patients  who 


1  Ohrenheilkunde  der  Gegenwart,  1860.     Berlin,  1861. 

•  Ohrenkrankheiten  und  Ohrenartze  in  England  and  Deutschland. 

3  Handbuch  der  Ohrenheilkunde,  p.  44.     Berlin,  1867. 


30  A   SKETCH   OF  THE 

needed  examinations  on  dark  days,  to  wait  until  the  sun  should 
shine.  He  frequently  visited  England,  and  had  quite  a  large 
consultation  practice  there.  He  unwittingly  did  much  to  deepen 
the  general  distrust  of  the  treatment  of  aural  disease. 

In  this  review  of  what  has  been  done  to  bring  otology  up  to 
its  present  position,  I  have  been  compelled  to  notice  the  difficul- 
ties with  which  the  advance  of  the  science  has  been  obliged  to 
contend  in  the  way  of  improper  and  unjust  criticism,  from  one 
who,  in  this  country  and  England,  acquired  the  reputation  of 
a  safe  guide  and  leader  in  this  part  of  the  field  of  medicine. 

Joseph  Williams '  (1839)  obtained  a  gold  medal  from  the  Uni- 
versity of  Edinburgh  for  a  monograph  upon  the  anatomy,  phys- 
iology, and  pathology  of  the  ear.  It  is  an  excellent  compilation 
of  the  knowledge  of  his  time,  written  in  a  pleasant  style,  ap- 
parently by  a  writer  with  very  little  or  no  experience  of  his 
own. 

George  Pilcher  (1841)  wrote  an  essay  on  the  ear,  which  re- 
ceived the  Fothergillian  gold  medal  from  the  Medical  Society  of 
London.  It  is  a  valuable  compilation.  The  section  on  foreign 
bodies  in  the  auditory  canal  is  full  of  warning  interest.  There 
is,  however,  very  little  of  the  author's  own  experience  in  the 
volume.2 

The  text-book  of  Wilhelm  Rau 3  is  written  in  an  attractive  style 
and  scientific  spirit,  but  unfortunately  for  its  permanent  hold 
upon  the  profession,  it  does  not  anticipate  the  real  advance  so 
soon  to  be  made  by  Trdltsch  in  giving  us  a  simple  method  of  ex- 
amining the  drum-head,  the  stand-point  for  modern  otology, 
just  as  much  as  Sims's  speculum  is  for  gynaecology,  and  it  has  a 
place  among  books  written  from  the  knowledge  of  the  ancients. 

The  work  of  James  Yearsley,4  although  having  some  unscien- 
tific characteristics,  as  its  title  would  indicate,  is  a  valuable 
book,  especially  for  its  sound  doctrine  with  regard  to  the  origin 
of  most  cases  of  impaired  hearing  in  the  mucous  membrane 
lining  the  throat,  nose,  and  ear,  and  for  its  account  of  the  dis- 
covery of  the  artificial  membrana  tympani. 

The  profession  has  of  late  become  more  alive  to  the  value 
of  Yearsley's  artificial  drum-head,  which,  as  is  well  known,  is 
formed  of  cotton,  by  the  papers  of  American,  German,  and  Eng- 
lish otologists,  but  nothing  essentially  new  has  been  added  to 
the  original  statements  of  its  inventor.  The  history  of  the  man- 

1  Treatise  on  the  Ear.     London:  Churchill,  1840. 

2  Treatise  on  the  Structure,  Economy,  and  Diseases  of  the  Ear.     American  edition, 
1343. 

3  Lehrbuch  der  Ohrenheilkunde.     Berlin,  1856. 

4  Deafness,  Practically  Illustrated.     Sixth  edition.     London,  1863. 


PROGRESS   OF   OTOLOGY.  31 

ner  in  which  the  value  of  an  artificial  membrana  tympani  was 
suggested  to  Yearsley  is  interesting. 

In  1841  a  gentleman  from  New  York  consulted  Dr.  Years- 
ley,  in  London,  in  regard  to  his  deafness,  who  informed  Dr. 
Y.  that  he  was  enabled  to  improve  his  hearing  power  so 
that  he  could  produce  in  his  left  ear  a  degree  of  hearing  quite 
sufficient  for  all  ordinary  purposes.  This  was  done  by  the  in- 
troduction "  of  a  spill  of  paper  previously  moistened  with  cotton 
to  the  bottom  of  the  passage  upon  the  remains  of  the  membrana 
tympani."  l 

This  was  the  real  discovery  of  the  artificial  membrana  tym- 
pani, although  Dr.  Martel  Frank,  in  his  cyclopaedic  text-book, 
refers  to  a  means  of.  preventing  injury  to  the  ear,  but  not  of  im- 
proving the  hearing  when  the  membrana  tympani  is  lost,  by 
the  use  of  a  silver,  gold,  or  lead  tube,  the  inner  end  of  which 
is  covered  by  a  membrane.  The  fact  that  such  a  means  of  pro- 
tecting the  ear  was  used  in  1640  has  been  already  alluded  to. 
It  cannot  be  said,  however,  to  be  an  artificial  membrana  tym- 
pani in  the  sense  of  Yearsley's  cotton- wool,  which  he  soon  sub- 
stituted for  the  paper  of  the  New  York  patient,  or'of  Toynbee's 
disk  of  rubber  attached  to  a  wire.  The  artificial  membrana 
tympani  has  proved  itself  a  very  valuable  means  of  treatment, 
and  is  in  constant  use  by  many  of  those  who  treat  suppurations 
of  the  middle  ear.*  Of  late  years,  the  use  of  the  artificial  drum- 
head has  assumed  great  importance  in  the  minds  of  the  laity,  by 
its  recommendation  for  all  diseases  of  the  ear,  by  interested  ad- 
vertisers, who  describe  it  as  a  new  invention,  and  sell  it  for  a 
very  large  price. 

The  work  of  Dr.  Frank,3  already  alluded  to,  will  be  found  a 
valuable  work  of  reference,  although  it  lacks  individuality. 
Hoffman's  mode  of  examining  the  auditory  canal  and  mem- 
brana tympani  is  fully  described  by  Frank  on  page  49  of  his 
book ;  but  he  attached  no  importance  to  it,  not  foreseeing 
that  it  was  to  supersede  all  other  methods,  as  it  has  done,  as  im- 
proved and  brought  into  general  use  by  Von  Troltsch. 

The  work  of  William  R.  Wilde  4  (1843),  surgeon  to  St.  Mark's 
Hospital,  which  was  republished  in  this  country,  where  it  has 
had  a  large  circulation,  and  which  was  translated  into  German, 
probably  did  more  to  place  our  science  upon  a  sound  basis,  than 
anything  that  has  been  done  in  otology  since  the  days  of  Val- 

1  Loc.  cit,  p.  221. 
8  Frank,  p.  293. 

3  Practische  Anleitung  zur  Erkenntniss  und  Behandlung  der  Ohrenkraukheiten. 
Erlanger,  1845. 

4  Practical  Observations  on  Aural  Surgery.     London,  1853. 


32  A   SKETCH   OF   THE 

salva.  This  work  was  founded  on  the  observations  of  a  careful 
observer,  who  had  acquired  fine  habits  of  study  as  a  skilful 
ophthalmologist.  It  was  not,  as  the  works  of  Lincke  and  Frank, 
a  cyclopaedia  of  what  had  been  written  on  otology,  nor  did  it 
contain  absurd  theories  like  that  of  Kramer,  but  it  consisted 
in  the  application  of  thorough  anatomical,  physiological,  and 
therapeutical  knowledge  to  the  study  of  an  organ  that  had 
been  hitherto  treated  as  if  it  were  something  different  from 
any  other  part  of  the  body,  and  not  subject  to  the  same  ac- 
cidents and  diseases,  and  consequences  of  those  diseases,  as 
other  parts  made  up,  in  like  manner,  of  integument,  of  carti- 
lage, mucous  membrane,  periosteum,  and  bone.  In  fact,  Wilde 
— afterward  Sir  William  Wilde,  in  consequence  of  the  well- 
earned  recognition  of  his  Queen — brought  otology,  or  aural  sur- 
gery as  he  called  this  department,  down  from  the  terra  incog- 
nita of  the  ancients  to  a  point  where  it  could  be  investigated  by 
the  average  practitioner,  and  where  it  was  respected  by  all.  He 
gave  us  the  conical  specula,  reviving  a  suggestion  of  Dr.  New- 
burg,  of  Brussels,  and  Ignaz  Gruber,  of  Vienna,  and  drove  the 
unhandy  ones  of  Fabricius  and  Kramer  out  of  use.  More  than 
all,  he  taught  us  that  the  true  nature  of  aural  disease  was  in- 
flammatory in  a  large  proportion  of  cases.  With  this  as  a  stand- 
point, he  inaugurated  a  successful  system  of  antiphlogistic 
treatment  by  means  of  incisions  in  tense  tissue,  local  blood-let- 
ting, blisters,  the  administration  of  mercury,  and  so  forth.  This 
system,  although  modified  and  enlarged,  still  obtains  with  our 
wisest  practitioners,  and  is  an  everlasting  monument  to  the 
genius  of  its  promulgator.  He  displaced  the  fanciful  and  theo- 
retical notions  of  Kramer,  which  were  having  wide  credence,  to 
the  great  detriment  of  the  scientific  knowledge  of  the  nature 
and  treatment  of  diseases  of  the  ear.  He  was  the  first  author 
to  place  aural  surgery  upon  a  rational  basis.  Wilde  deserves 
the  title  of  the  Father  of  Modern  Otology. 

Then  came  Toynbee's  book  '  (1860),  which  is  mainly  valuable 
for  its  anatomical  and  pathological  investigations.  It  can  never 
take  rank  with  Wilde's  book  as  a  useful  treatise  for  the  practi- 
tioner, indispensable  as  were  Toynbee's  labors  as  an  anatomist 
and  pathologist.  Mr.  James  Hinton's  supplement,  however, 
materially  improved  Toynbee's  treatise. 

Dr.  Anton  von  Troltsch  (1861 ),  of  Wiirzburg,  published  a  mono- 
graph2 upon  the  anatomy  of  the  ear,  in  1861,  which  he  entitled 

1  The  Diseases  of  the  Ear :  their  Nature,  Diagnosis,  and  Treatment.  Reprint. 
Philadelphia,  1860.  The  same,  with  a  supplement,  by  James  Ilinton,  F.R.S.  Lon- 
don, 1868. 

*  Die  Anatomie  des  Ohres.     Wiirzburg,  1861. 


PROGEESS   OF   OTOLOGY.  33 

a  contribution  to  the  scientific  establishment  of  otology.  It  was 
certainly  all  that  and  something  more.  While  it  gave  a  very 
simple  and  complete  account  of  the  anatomy,  except  that  of  the 
internal  ear,  there  were  many  wise  suggestions  in  the  text 
with  regard  to  the  treatment  of  aural  disease.  Troltsch  showed 
himself  to  be  a  disciple  of  Wilde  and  Toynbee.  He  built  upon 
the  foundations  which  the  clinical  skill  of  the  Irish,  and  the 
pathological  labors  of  the  English  observer  had  made,  and 
brought  otology  in  Germany  into  a  position  which  made  it  an 
inviting  department  of  labor.  His  work  upon  the  anatomy  con- 
tains the  results  of  many  original  investigations,  which  will  be 
found  in  the  anatomical  descriptions  of  this  volume. 

This  work  on  the  anatomy  of  the  ear  was  soon  followed  by  a 
text-book  upon  its  diseases,1  which  had  the  same  scientific  char- 
acteristics with  the  monograph  upon  the  anatomy.  It  has  been 
translated  into  the  English,  French,  and  Italian  languages.  In 
this  country  it  met  with  great  favor,  having  passed  through  two 
editions,  and  it  has  given  tone  to  all  the  otological  literature  and 
investigations  of  its  day.  Troltsch  improved  and  brought  into 
general  use  the  method  of  examination  of  the  canal  and  drum- 
head first  proposed  by  Dr.  Hoffman,  of  Westphalia — which  had 
been  entirely  forgotten  by  the  profession — and  thus  at  one  step 
advanced  the  science  very  materially. 

In  1862,  the  same  year  that  Von  Troltsch  issued  his  text-book, 
Dr.  Adam  Politzer,  of  Vienna,  promulgated  his  method  of  inject- 
ing air  into  the  middle  ear,  the  so-called  inflation.  It  is  hard 
to  overestimate  the  value  of  this  simple  procedure,  and  the 
benefit  to  our  science  and  art  that  its  invention  caused.  The 
writer  can  but  quote  the  opinion  of  an  eminent  practitioner  of 
this  city,  of  large  experience  in  aural  disease,  who,  in  speaking 
of  Politzer's  method,  once  said  to  him  :  "If  a  man  were  to  take 
this  air-bag  and  travel  through  the  country,  advertising  himself 
as  an  aurist,  and  blow  up  all  the  ears  indiscriminately  that  were 
brought  to  him,  he  would  be  a  very  successful  quack.''  Indeed, 
the  effects  of  this  means  of  treatment,  especially  in  the  case  of 
children,  or  even  adults,  who  have  suffered  but  a  short  time 
from  impairment  of  the  hearing,  from  disease  of  the  middle  ear, 
are  often  wonderful. 

Toynbee  just  missed  making  the  discovery  of  this  method  of 
inflating  the  ear,  in  his  physiological  investigations  as  to  the  po- 
tency of  the  Eustachian  tube,  and  especially  when  he  proved 
that  it  was  opened  by  the  act  of  swallowing.  Politzer  evidently 
followed  Toynbee's  investigations  very  carefully,  and  with  rare 

1  Die  Krankheiten  des  Ohres, 


34  A   SKETCH   OF   THE 

wisdom  availed  himself  of  them  to  make  an  invaluable  addition 
to  our  means  of  treating  the  ear. 

The  late  Dr.  Julius  Erhard  (1863)  published  a  work  upon  the 
diseases  of  the  ear,1  which  is  a  peculiar  mixture  of  truth  with 
error.  Most  of  its  theories  are  based  upon  imperfect  observa- 
tions and  are  misleading  in  the  extreme.  It  has  little  or  no 
practical  value. 

In  1864  Dr.  von  Troltsch,  Dr.  Politzer,  and  Dr.  Herman 
Schwartze,  of  Halle,  issued  the  first  number  of  the  Archiv.  filr 
Ohrenheilkuride,  a  work  which  has  been  regularly  continued 
under  their  management,  and  which  has  formed  a  true  guide  to 
the  otological  student  and  practitioner. 

In  1865  Dr.,  now  Professor,  Politzer  published  a  monograph 
upon  the  membrana  tympani,  which  was  translated  into  English 
and  published  in  the  United  States  by  my  friends  and  colleagues 
Drs.  Arthur  Mathewson  and  Homer  P.  Newton,  of  Brooklyn. 
This  monograph  was  the  first  serious  study  of  the  drum-head, 
and  holds  a  high  place  in  otological  literature. 

In  October,  1867,  the  first  number  of  the  Monatsschrift  filr 
Ohrenheilkunde  was  issued,  under  the  direction  of  Dr.  Voltolini, 
of  Breslau  ;  Dr.  Josef  Gruber,  of  Vienna  ;  Dr.  F.  E.  Weber,  of 
Berlin  ;  and  Dr.  N.  Riidinger,  of  Munich.  This  journal  is  still 
continued,  with  the  addition  of  a  department  devoted  to  diseases 
of  the  throat.  All  of  these  editors  have  contributed  very  much 
to  the  scientific  advance  of  otology  ;  while  Dr.  Riidinger  has 
probably  done  more  than  any  anatomist  of  his  day  to  elucidate 
the  anatomy  of  the  Eustachian  tube.  His  photographic  atlas  of 
the  ear  is  a  work  of  permanent  value,  and  one  of  which  the 
author  has  made  frequent  use  in  illustrating  some  of  the  chap- 
ters of  this  work. 

Dr.  S.  Moos,4  of  Heidelberg,  issued  a  practical  treatise  on  aural 
disease  in  1866,  and  Dr.  Gruber,3  of  Vienna,  one  in  1870.  Both  of 
these  volumes  show  much  original  research,  and  are  worthy  of 
an  English  translation,  which  would  bring  them  before  a  much 
larger  circle  of  readers. 

The  American  Otological  Society  was  established  in  1868,  and 
has  held  annual  meetings  since,  and  has  published  thirteen  vol- 
umes of  "  Transactions."  To  these  papers  the  author  has  had  fre- 
quent occasion  to  refer  in  the  preparation  of  the  following  chap- 
ters, and  it  is  believed  that  they  furnish  evidence  of  the  high 
character  of  the  work  that  has  been  done  by  American  otologists. 

1  Klinische  Otiatrie.     Berlin. 
*  Klinik  der  Ohrenkrankheiten. 
3  Lehrbucli  der  Ohrenheilkunde. 


PROGRESS   OF   OTOLOGY.  35 

No  outline  of  what  has  been  done  in  the  last  twenty  years 
for  otology  would  be  complete  without  a  reference  to  the  writ- 
ings of  the  late  Professor  Edward  H.  Clarke,  of  Harvard  Uni- 
versity. Dr.  Clarke  published  a  paper  on  perforations  of  the 
membrana  tympani, '  its  causes  and  treatment,  which  was  prob- 
ably the  best  that  had  been  written  on  this  subject.  It  received 
a  full  recognition  among  foreign  authorities.  This  article  con- 
tains a  very  important  sentence,  quoted  by  Troltsch  in  his  text- 
book, a  passage  full  of  meaning  and  warning  :  "  So  necessary  is 
a  careful  attention  to  the  ear,  during  the  course  of  an  acute  ex- 
anthema, that  every  physician  who  treats  such  a  case  without 
careful  attention  to  the  organ  of  hearing,  must  be  denominated 
an  unscrupulous  practitioner."  Dr.  Clarke  also  published  a 
monograph  upon  polypus  of  the  ear,  which  contains  very  much 
of  value  as  to  the  nature  and  treatment  of  these  products  of  in- 
flammation. 

In  1869,  Drs.  H.  Knapp,  of  New  York,  and  S.  Moos,  of  Heidel- 
berg, began  the  publication  of  the  Archives  of  Ophthalmology 
and  Otology,  which  are  issued  simultaneously  in  English  and 
German,  and  which  have  added  much  to  the  scientific  interest 
in  otology.  The  union  of  the  two  branches  of  science  in  so 
valuable  a  journal  has  certainly  assisted  to  gain  the  respect  of 
the  profession  for  the  department  of  otology.  In  1879  these  pub- 
lications were  separated,  and  the  author  of  the  present  work 
became  associated  with  Drs,  Knapp  and  Moos  in  the  publication 
of  the  journal  devoted  to  otology. 

In  1872,  Dr.  Laurence  Turnbull  issued  a  "Clinical  Manual  of 
the  Diseases  of  the  Ear."  In  1873,  the  first  edition  of  the  present 
treatise  on  the  ear  was  published.  In  the  same  year  Mr.  W.  B. 
Dalby,  of  London,  published  a  volume  of  lectures  upon  the  ear, 
which  is  of  permanent  value.  The  work  of  Dr.  A.  D.  Williams, 
of  St.  Louis,  was  also  published  in  this  year,  and  contains  many 
original  observations. 

Dr.  Weber  Liel's  *  (1873)  work  upon  the  nature  and  curability 
of  progressive  impairment  of  hearing,  is  a  monograph  which  has 
been  subjected  to  close  analysis  and  criticism  on  the  one  hand, 
and  from  which  much  has  been  borrowed  on  the  other.  It  is  an 
ingenious  and  interesting  work,  but,  in  the  opinion  of  the  au- 
thor of  this  work,  its  theories  have  not  been  substantiated. 

In  Italian,  the  work  of  Dr.  De  Rossi3  (1871)  is  written  in  the 


1  American  Journal  of  the  Medical  Sciences,  January,  1858. 

*  Ueber  das  Wesen  und  die  Heilbarkeit  der  haufigsten  form  progressiver  Schweho- 
rigkeit. 

3  Le  Mallattie  dell'  Orecchio. 


36  A   SKETCH   OF   THE 

spirit  of  the  modern  German  school,  and  forms  a  reliable  guide 
to  those  reading  that  language. 

One  of  the  most  valuable  works  that  has  ever  been  published 
upon  diseases  of  the  ear  is  the  one  entitled  "  The  Questions  of 
Aural  Surgery,"  by  the  late  James  Hinton  (1874).  It  is  written 
in  a  purely  scientific  spirit,  and  is  full  of  valuable  facts  and 
wise  observations,  while  it  suggests  much  for  more  thorough 
investigation.  It  was  accompanied  by  an  atlas  of  the  mem- 
brana  tympani,  consisting  of  one  hundred  and  fifty  pictures 
of  the  drum-head  in  water-color.  Literature  must  be  searched 
very  carefully  to  find  a  scientific  work  upon  any  subject  so 
essentially  honest  and  impartial  as  the  volume  entitled  "  Ques- 
tions in  Aural  Surgery." 

The  lectures  on  aural  catarrh,  by  the  late  Dr.  Peter  Allen 
(1870),  are  valuable  in  many  points.  The  second  edition  passed 
through  the  press  in  1874,  during  the  author's  last  illness.  The 
death  of  Dr.  Allen  was  a  loss  to  our  profession  of  a  hard- 
working and  ingenious  student  in  otology. 

Mr.  George  P.  Field  (1876),  the  successor  of  Toynbee  as  Aural 
Surgeon  to  St.  Mary's  Hospital,  published  a  small  octavo  upon 
the  ear,  which  has  some  unique  features,  especially  in  the  illus- 
trations of  the  various  forms  of  diseases  of  the  membrana  tym- 
pani, as  seen  through  the  speculum.  The  book  contains  many 
valuable  cases,  and  is  altogether  a  positive  contribution  to  aural 
medicine  and  surgery,  and  has  passed  into  the  second  edition. 

Among  the  most  valuable  of  the  text-books  on  the  ear  of  the 
present  day  is  that  of  Dr.  Charles  H.  Burnett  (1877).  The  part 
upon  anatomy  and  physiology  is  particularly  well  presented. 

The  monograph  upon  "  Deafness,  Giddiness,  and  Noises  in 
the  Head,"  by  Dr.  Edward  Woakes  (1879),  of  London,  hardly 
assumes  to  be  a  text-book.  Its  peculiar  views  are  chiefly  those 
of  Weber  Liel  of  Berlin,  and  will  be  alluded  to  in  certain  discus- 
sions in  this  volume.  The  author  is  enthusiastic  in  the  promul- 
gation of  his  views  of  the  causes  of  aural  affections.  His  work 
has  passed  to  a  second  edition,  and  he  has  adherents  in  this 
country. 

The  work  of  Dr.  H.  Macnaughton  Jones  (1881),  of  Cork,  also 
lays  great  stress  upon  Weber  Liel's  views  as  to  paretic  deafness, 
and  operations  upon  the  tensor  .tympani,  without,  however,  any 
claim  like  that  made  by  Woakes,  to,  have  been  coeval  with  the 
latter  author  in  his  views  upon  these  subjects. 

The  work  on  the  ear  by  Dr.  Albert  H.  Buck  (1880),  of  New 
York,  contains  a  vast  amount  of  valuable  research  in  otology. 
The  author's  experience  has  been  lafge,  and  every  one  interested 
in  otology  will  find  its  pages  very  interesting  and  instructive. 


PROGRESS   OF   OTOLOGY.  37 

Especially  to  be  mentioned  are  the  sketch  of  the  physiology  of 
the  ear,  the  chapter  upon  the  mastoid  process,  and  the  one  upon 
fractures  of  the  temporal  bone. 

Of  text-books  upon  the  ear  in  the  French  language  there  is 
very  little  to  be  said.  Modern  otology  finds  very  little  comfort 
in  such  works  as  those  of  Miot  and  Bonnafont,  although  the 
latter-named  author  has  laid  the  profession  under  obligations  by 
his  contributions  to  the  subject  of  exostosis. 

Among  the  recent  works  in  the  German  language  are  those 
of  Urbantschitsch,  of  Vienna,  Hartmann,  of  Berlin,  and  Politzer. 
The  work  of  the  first-named  author  is  an  elaborate  cyclopaedia, 
with  scarcely  a  trace  of  personal  coloring,  dreary  in  the  ex- 
treme, but  valuable  as  a  work  of  reference.  Politzer's  work 
upon  the  ear  is  worthy  of  the  expectations  raised  by  the  renown 
•of  its  author.  It  has  been  translated  into  excellent  English  by 
Dr.  Patterson  Cassells,  of  Edinburgh,  and  is  accessible  through 
an  American  publisher. 

In  1879,  The  American  Journal  of  Otology,  a  quarterly,  was 
founded  by  Dr.  Clarence  J.  Blake  in  conjunction  with  a  number 
of  eminent  aural  surgeons  and  physicists.  The  journal  was  es- 
tablished in  order  "to  afford  a  medium  for  the  publication  of 
original  communications  on  subjects  coming  within  the  scope  of 
the  two  departments  to  which  it  was  devoted,"  acoustics  and 
aural  surgery.  This  journal  was  ably  conducted,  but  the  publi- 
cation ceased  with  the  fourth  volume  in  1882. 

There  is  also  a  French  journal1  devoted  to  diseases  of  the  ear, 
in  conjunction  with  those  of  the  larynx,  which  furnishes  many 
original  articles  as  well  as  a  fair  digest  of  foreign  literature. 

The  latest  work  on  the  ear  that  has  appeared  up  to  the  time 
of  the  writing  of  this  chapter,  is  that  by  Dr.  Oren  D.  Pomeroy, 
long  and  favorably  known  to  the  profession  as  an  original  and 
industrious  worker  in  otology.  His  volume  contains  the  result  of 
the  author's  large  experience,  with  a  compendium  of  that  of 
others,  written  in  a  judicial  spirit. 

Lincke,  writing  in  1840,  regrets  that  in  Germany  no  clinique 
for  the  treatment  of  aural  patients  had  as  yet  been  organized. 
Dr.  Reiner,  he  says,  had  attempted  to  do  so  in  Munich,  but  had 
failed,  as  had  Dr.  Lincke  in  Leipsic ;  and  we  know  that  Saun- 
ders  and  Cooper  had  failed  in  establishing  one  in  London  ;  for 
in  1804,  Saunders  had  an  eye  and  ear  infirmary  in  London,  under 
the  name  of  the  "  New  London  Dispensary  for  Curing  Diseases 
of  the  Eye  and  Ear."  But  the  aural  part  was  so  unsuccessful, 
that  it  became  necessary  to  close  it  to  the  aural  practice.  John 

1  Annales  des  Maladies  de  POreille  et  du  Larynx. 


38  A   SKETCH    OF  THE 

Harrison  Curtis,  in  1816,  was  more  successful,  and  when  Lincke 
wrote  his  dispensary  was  still  carried  on.  In  1828,  the  New 
York  Eye  and  Ear  Infirmary,  which  had  been  in  existence 
eight  years,  treated  91  cases  of  diseases  of  the  ear  to  925  of 
diseases  of  the  eye.  That  institution,  according  to  its  last  pub- 
lished report,  treated  more  than  2,800  aural  cases.  In  the  Man- 
hattan Eye  and  Ear  Hospital,  New  York,  1,809  aural  cases  were 
examined  in  the  last  year  ;  in  the  Ophthalmic  and  Aural  Insti- 
tute, 1,579 ;  and  in  the  Brooklyn  Eye  and  Ear  Hospital,  1,731. 
These  facts  indicate  that  due  scientific  attention  is  being  at  last 
given  to  the  ear. 

In  New  York  City,  there  are  five  special  hospitals  for  the 
treatment  of  aural  diseases,  in  conjunction  with  diseases  of  the 
eye— a'  union  which  seems  to  find  favor  chiefly  in  the  United 
States,  Ireland,  and  Canada. 

The  marked  distrust  with  which  the  profession  at  large  re- 
garded the  theories  of  the  nature  and  treatment  of  aural  disease, 
did  not  begin  to  give  way  until  the  views  of  Wilde  became  gen- 
erally known  and  accepted.  It  was  not,  however,  until  a  simple 
and  practical  means  of  examining  the  auditory  canal  and  mem- 
brana  tympani  had  been  suggested  and  accepted,  that  otology 
became  an  inviting  field  of  professional  labor. 

The  next  step  was  to  recognize  the  pharynx  as  the  starting- 
point  of  the  diseases  of  the  middle  ear,  and  to  separate  these 
from  the  less  frequently  occurring  cases  of  diseases  of  the  ex«- 
ternal  ear.  With  this  came  a  simple  means  of  opening  and 
treating  the  Eustachian  tube  and  the  tympanic  cavity.  If  now, 
we  can  succeed  as  I  believe  we  are  about  to  succeed,  in  separat- 
ing affections  of  the  nerve  from  those  of  the  middle  ear,  that  is 
to  say,  diseases  of  the  perceptive  apparatus  from  those  of  the 
parts  devoted  to  the  conduction  of  sound,  otology  will  take  rank 
with  ophthalmology  for  exactness  in  diagnosis  and  prognosis. 

If  any  cause  remain  for  looking  askance  at  the  claims  of 
otology,  it  is  to  be  found  in  the  attitude  of  those  otologists  who, 
in  a  spirit  quite  out  of  keeping  with  true  medical  philosophy, 
devote  too  much  of  their  energy  to  the  explication  of  the  causes 
and  treatment  of  incurable  aural  diseases,  and  who  lay  too  little 
stress  upon  recent  affections  and  the  hygienic  knowledge  which 
may  prevent  insidious  and  incurable  diseases  of  the  ear,  and  who 
reject  all  attempts  at  an  exact  diagnosis  of  affections  of  the 
labyrinth,  declaring  themselves  agnostics,  at  a  time  when  faith 
and  works  may  bring  to  us  a  knowledge  of  what  they  declare  to 
be  beyond  human  ken. 

In  concluding  this  introductory  chapter,  I  beg  that  the  reader 
will  bear  in  mind  that  I  have  not  attempted  to  make  it  more  than 


PROGRESS   OF   OTOLOGY.  39 

an  outline  of  what  has  been  done  in  otology  from  the  earliest 
times  until  our  own  day.  I  have  endeavored  to  sketch  only  that 
which  has  left  its  traces  upon  the  science,  and  which  has  con- 
tributed materially  to  its  progress.  I  have  merely  desired  to 
give  such  a  historical  account  of  the  work  of  the  fathers,  as 
would  render  any  frequent  references  to  them  unnecessary  in 
the  body  of  this  work,  and  one  which  may  be  a  guide  and  en- 
couragement for  those  who  are  interested  in  this  department  of 
medicine. 


AUTHOBITIES  CONSULTED  IN  PREPARING  THE  PRECEDING  HIS- 
TORICAL SKETCH. 

For  the  convenience  of  the  reader  who  may  desire  to  consult  the  original  authorities  which  the  author 
has  examined  in  preparing  the  preceding  sketch,  their  complete  titles  are  here  given.  The  bibliography 
will,  however,  be  seen  to  refer  only  to  the  works  actually  examined,  and  not  to  those  mentioned  as  quoted 
by  the  authorities  themselves. 

Archiv  fur  Ohrenheilkunde.  Herausgegeben  von  A.  Von  Troltsch,  A.  Politzer, 
und  H.  Schwartze.  Wiirzburg.  I.-VL,  Neue  folge  I.-XIX. 

Archives  of  Ophthalmology  and  Otology.  Edited  and  published  simultaneously 
in  English  and  German,  by  Professor  H.  Knapp,  in  New  York,  and  Profes- 
sor S.  Moos,  in  Heidelberg.  New  York  :  William  Wood  &  Co.  Carlsruhe : 
Chr.  F.  R.  Miillersche  Hof-Buchhandlung,  1869-72. 

Archives  of  Otology,  Edited  in  English  and  German  by  Dr.  H.  Knapp,  Dr.  S. 
Moos,  and  Dr.  D.  B.  St.  John  Roosa. 

ALLEN,  PETEB.     Lectures  on  Aural  Catarrh.     London :   J.  &  A.  Churchill,  1871. 

The  Same.     Second  edition.     1874. 

American  Journal  of  Otology.  Edited  by  S.  Clarence  J.  Blake,  in  conjunction 
with  Professor  A.  M.  Mayer,  of  Hoboken  ;  Alexander  Graham  Bell,  Dr.  El- 
liott Coues,  U.S.A.,  Professor  A.  Dolbear,  Dr.  Albert  H.  Buck,  Dr.  Samuel 
Sexton,  Dr.  J.  Orne  Green,  Dr.  H.  N.  Spencer.  New  York,  1879-1883. 

Annales  des  Maladies  de  1'Oreille  et  du  Larynx.  Fondees  et  Publiees  par  MM. 
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BAKR,  THOMAS.    Manual  of  Diseases  of  the  Ear.     Glasgow  :  1884. 

BECK,  KARL  JOSEPH.  Die  Krankheiten  des  Gehoerorganes.  Heidelberg  und 
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BURNETT,  CHARLES  H.  The  Ear :  Its  Anatomy,  Physiology,  and  Diseases. 
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BUCK,  ALBERT  H.  A  Manual  of  Diseases  of  the  Ear.  Second  edition.  New 
York  :  William  Wood  &  Co.,  1889. 

BONNAFONT,  DR.  I.  P.  Traite  theorique  et  pratique  des  Maladies  de  1'Oreille  et 
des  Organes  de  1'audition.  Deuxieme  edition  revue  et  augmentee.  Paris  : 
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Edition.  Paris  :  J.  B.  Balliere,  1836. 


40  A  SKETCH  OF  THE 

• 

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Anatomy  of  the  Organ.  Second  edition,  from  the  fourth  German.  Trans- 
lated and  edited  by  D.  B.  St.  John  Roosa.  New  York :  William  Wood  & 
Co.,  1869. 

TBOLTSCH,  VON  ANTON.  Gesammelte  Beitrage  zur  Pathologischen  Anatomie  des 
Ohres.  Leipzig,  1883. 

TUBNBULL,  LAWBENCE.  A  Clinical  Manual  of  the  Diseases  of  the  Ear.  Philadel- 
phia :  J.  B.  Lippincott  &  Co.,  1872. 

UBBANTSCHITSCH,  DR.  VICTOB.  Lehrbuch  der  Ohrenheilkunde.  Wien  und  Leip- 
zig :  Urban  &  Schwarzenberg,  1880. 

Valsalvse  Opera.  Viri  celeberinni  Antonii  Marise.  Tractatus  de  Aure  Humana. 
.  .  .  .  Omnia  recensuit  et  auctoris  vitam  addivit  Joannes  Baptista 
Morgagnus.  Lugduni :  Batavorum  apud  Johannem  Hasebroek,  1742. 


PROGRESS   OF   OTOLOGY.  43 

WILDE,  WILLIAM  B.     Some  Observations  on  the  Early  History  of  Aural  Surgery, 

and  the  Nosological  Arrangement  of  Diseases  of  the  Ear,  by  W.  B.  Wilde, 

M.E.I.A.   The  Dublin  Journal  of  Medical  Science,  Vol.  XXV.   Dublin,  1844. 
WILDE,  WILLIAM  B.    Practical  Observations  on  Aural  Surgery,  and  the  Nature 

and  Treatment  of  Diseases  of  the  Ear,  by  William  B.  Wilde.   London  :  John 

Churchill,  1853. 
WEBER  LIEL,  DR.  FR.  E.      Ueber  das  Wesen  und  die  Heilbarkeit  der  haufigsten 

form  progressiver  Schwerhorigkeit-Untersuchungen  und  Beobachtungen. 

Berlin  :  August  Hirschwald,  1873. 
WILLIAMS,  JOSEPH.     Treatise  on  the  Ear,  including  its  Anatomy,  Physiology, 

and  Pathology.     London  :  John  Churchill,  1840. 
WILLIAMS,  A.  D.     Diseases  of  the  Ear.     Including  the  necessary  anatomy  of  the 

organ.     Cincinnati :  Bobert  Clarke  &  Co.,  1873. 
WILLIS,  THOMAS.     Opera  Omnia.     Amsterdamna  apud  Henricum  Wetstenium. 

Pars  Physiologica,  Cap.  XTV.,  p.  69. 
WOAKES,  EDWARD,  Lond.     On  Deafness,  Giddiness,  and  Noises  in  the  Head. 

Second  edition,  enlarged  and  revised.     London :  H.  K.  Lewis.  136  Gower 

Street,  W.  C. 
YEARSLEY,  JAMES.    Deafness  Practically  Illustrated.     Being  an  Exposition  of 

the  Nature,  Causes,  and  Treatment  of  Diseases  of  the  Ear.    Sixth  edition. 

London  :  John  Churchill  &  Sons,  1863. 


CHAPTER  II. 

THE  EXAMINATION  OF  AUEAL  PATIENTS. 

History. — Power  of  Hearing  Conversation. — Test  Sentences. — Tick  of  a  Watch. — Tun- 
ing-fork.— Aerial  and  Bone  Conduction. — Malingering. — Angular  Forceps. — 
Specula. — Troltsch's  Otoscope. — Examination  of  Pharynx. — Rhinoscopy. — Use  of 
Eustachian  Catheter. — Politzer's  Method  and  its  so-called  Modifications. — Bou- 
gies.— Valsalva's  Method. 

IT  is  a  self-evident  proposition,  that  in  order  to  intelligently 
treat  any  disease  we  must  carefully  and  thoroughly  examine 
the  parts  involved.  This  is  certainly  as  true  of  the  affections  of 
the  ear  as  it  is  of  those  of  any  other  organ.  In  making  such  an 
examination  a  definite  plan  should  be  followed,  even  in  the 
seemingly  simple  cases,  until  at  last  a  large  experience  enables 
the  practitioner  to  omit  or  hurry  over  some  of  the  details  which 
were  necessary  in  the  beginning  of  his  practice. 

In  the  examination  of  an  aural  patient,  the  following  method 
is  the  one  that  I  have  found  very  useful : — I  usually  keep  a 
record  of  the  cases  ;  a  plan  which  the  young,  and  consequently 
not  very  busy  practitioner  will  find  extremely  valuable.  The 
name,  age,  and  occupation  of  the  patient  are  noted.  The  history 
should  then  be  given.  This  history  should  include  a  pretty  full 
statement  of  the  general  condition,  the  diseases  from  which  the 
patient  has  suffered,  the  number  of  times  he  has  had  what  is 
called  "  earache,"  the  medication  to  which  he  has  been  sub- 
jected, and  so  on,  from  his  earliest  recollections  until  the  date 
of  his  coming  under  observation  as  an  aural  patient. 

By  no  other  means  than  by  eliciting  such  a  history,  can  the 
practitioner  get  the  essential  knowledge  for  a  thorough  under- 
standing of  the  subjective  manifestations  of  the  affection  of  the 
ear.  It  is  very  important  to  ascertain  when  the  troublesome 
symptoms  were  first  observed.  Sometimes  several  minutes  will 
be  consumed  in  obtaining  an  answer  to  this  question.  The  first 
reply  will  be,  perhaps,  "A  few  months  ago,"  or,  "A  year  or 
two."  If  this  response  be  followed  by  the  inquiry,  "  Before  that 
time  were  your  ears  perfectly  well  ?  "  in  many  instances  the  pa- 
tient will  state,  "  Well,  no.  I  have  had  a  little  dulness  of  hear- 


THE  EXAMINATION   OF  AURAL   PATIENTS.  45 

ing  on  one  side  for  ten  or  twelve  years,  or  for  a  good  while " 
(which  proves  to  be  a  number  of  years) ;  or  perhaps  he  says, 
"There  has  been  a  little  discharge  from  that  ear,  'which  didn't 
amount  to  much,'  ever  since  I  had  the  scarlet  fever  or  the 
measles."  As  illustrative  of  this  point,  I  may  mention  a  case 
which  lately  came  to  my  clinic.  The  patient,  an  old  man,  gave 
the  following  history  :  While  sitting  quietly  by  the  fire,  blood 
began  to  run  from  his  ears,  until  he  had  lost  quite  an  amount ;  he 
stated  positively  that  this  was  the  first  time  in  all  his  long  life, 
that  he  had  ever  had  any  kind  of  an  affection  of  the  ear,  and 
that  he  could  imagine  no  cause  for  it.  On  close  examination  in 
the  manner  of  questioning  above  indicated,  he  admitted  that  he 
had  suffered  from  a  "  slight  running  from  the  ears,  which  didn't 
signify,  ever  since  he  was  a  child."  An  inspection  of  the  or- 
gans showed  that  both  membranae  tympani  were  removed  by 
ulceration,  and  that  large  granulations  existed.  These  condi- 
tions of  course  accounted  for  the  seemingly  mysterious  hemor- 
rhage, to  which  the  patient  could  assign  no  cause. 

It  is  well  in  obtaining  the  history  to  allow  the  patient  to  tell 
his  own  story,  occasionally  interrupting  him,  as  may  be  neces- 
sary, in  order  to  keep  him  to  the  matter  in  hand.  After  having 
thus  obtained  as  accurate  an  account  as  possible,  the  next  step 
is  to  test  the  power  of  hearing. 

The  tests  of  the  hearing  power  usually  employed  are  : 

1.  Ordinary  conversation. 

2.  The  tick  of  a  watch. 

3.  The  tuning-fork. 

'Many  attempts  have  been  made  to  produce  an  instrument 
that  will  so  accurately  test  the  hearing  power  as  to  supersede 
the  imperfect  tests  that  even  all  these  three  constitute.  As  yet 
success  has  not  been  attained.  Politzer,1  after  admitting  that 
the  instruments  as  yet  invented  are  useless  for  the  precise  esti- 
mation of  the  degree  of  impairment  of  hearing,  describes  his 
own  acoumeter.  In  this  instrument  the  tone  is  produced  by  the 
striking  of  a  hammer  upon  a  steel  cylinder,  which  is  connected 
by  a  screw  with  a  perpendicular  vulcanite  column.  I  have 
tested  it  thoroughly,  but  I  see  no  advantage  in  it  over  a  watch, 
if  the  latter  be  carefully  tested,  so  that  the  average  distance  at 
which  it  can  be  heard  by  persons  with  good  hearing  power  is 
known. 

The  power  of  hearing  conversation,  perhaps  tells  the  most 
about  a  person's  practical  hearing  power,  and  yet  it  is  difficult 
to  test  it.  About  the  best  test  of  the  hearing  power  that  we 

1  Text-book.     English  translation,  p.  163. 


46  TEST   SENTENCES. 

have,  is  the  one  which  shows  the  patient's  capability  for  hearing 
what  is  said  in  social  intercourse,  at  the  table,  in  the  drawing- 
room,  and  so  on.  Inasmuch,  however,  as  practitioners,  espe- 
cially those  who  live  in  large  cities  and  towns,  have  not  always, 
or  even  usually,  the  opportunity  of  making  such  a  test  of  their 
patient's  hearing  capabilities,  and  since  the  amount  of  this 
power,  although  it  may  be  appreciated  by  the  observer  himself, 
cannot  be  made  clear  to  one  who  simply  reads  the  case,  we  are 
obliged,  in  recording  the  histories  of  patients,  to  be  content  with 
noting  at  what  distance  words  can  be  understood  when  they  are 
directed  to  the  person  observed,  with  his  face  so  placed  that  he 
cannot  see  the  mouth  of  the  speaker.  This  latter  precaution  is 
an  essential  one,  since  all  persons  with  impaired  hearing  soon 
learn  to  watch  the  lips  of  the  speaker,  in  order  to  compensate 
for  their  loss  of  hearing  power. 

Dr.  A.  H.  Buck :  has  made  an  attempt  to  furnish  test  sentences 
so  that  all  the  members  of  any  one  group  or  class  should  be  as 
nearly  as  possible  equal  in  value  in  penetrating  power.  Ex- 
amples of  such  equivalent  test  sentences  are  given  by  Dr.  Buck, 
as  follows  : 

1.  Pour  oil  on  the  waters  of  Lake  Erie. 

2.  All  hail  !  thou  hero  of  fourteen  wars. 

Each  of  these  sentences  contains  eight  long  vowel  sounds 
and  are  equally  free  from  non-resonant,  consonant,  or  short 
vowel  sounds. 

Dr.  Buck a  has  found,  however,  that  the  objections  to  these 
test  sentences  are  practically  insurmountable,  and  he  does  not 
think  they  can  be  made  available  to  any  extent ;  yet  in  a  rude 
way,  I  think  we  may  make  them  of  use.  I  come  more  and 
more  to  the  use  of  this  test  of  words  spoken  as  near  as  may 
be  in  an  ordinary  tone,  as  being  the  one  that  conveys  the  best 
idea  of  the  hearing  power.  On  the  other  hand,  I  am  more  and 
more  distrustful  of  the  watch  as  a  means  of  testing  the  hearing. 
This  remark  applies  also  to  the  acoumeter.  I  shall  long  re- 
member the  critical  remark  of  a  boy  once  under  my  care  for 
impaired  hearing,  who  after  submitting  for  some  time  with  pa- 
tience to  a  test  of  his  power  of  hearing  a  watch  tick,  finally  ex- 
claimed :  "  I  don't  care  to  hear  the  watch  ;  what  I  want  to  hear 
is  what  people  say  to  me."  Since  this  incident,  I  have  endeav- 
ored to  learn  the  capability  of  the  patient  to  hear  conversation 
under  ordinary  circumstances  by  a  test  of  the  hearing  power, 
and  when  I  wish  to  demonstrate  an  improvement,  I  induce  a 

1  Report  of  the  First  International  Otological  Society.     New  York :  Appleton,  1877. 
*  Treatise  on  the  Ear,  p.  18. 


TESTING  HEAKING   BY   A   WATCH.  47 

friend  of  the  patient  to  converse  with  him,  under  conditions  the 
same  as  those  that  existed  before  the  improvement  took  place. 

In  testing  the  hearing  by  means  of  the  watch,  it  should  be 
first  placed  at  a  distance  at  which  its  ticking  cannot  be  heard 
by  the  patient,  and  then  gradually  approached  to  a  situation 
where  the  ticks  can  be  accurately  counted.  The  latter  may 
fairly  be  considered  as  the  farthest  point  of  distinct  hearing. 
The  hearing  power  is  sometimes  tested  by  placing  the  watch 
where  it  can  be  certainly  heard  and  then  withdrawing  it  to  the 
furthest  limit  at  which  its  sound  can  be  perceived.  This  is  a 
fallacious  test,  for  the  sound  once  perceived,  it  is  eas}r  for  a  de- 
fective ear  to  follow  it  until  it  reaches  a  distance  far  beyond  its 
normal  range  of  hearing.  The  ear  which  is  not  being  tested 
should  be  closed  by  the  hand  during  the  examination.  It  is  not 
possible  to  state  the  distance  at  which  a  watch  should  be  heard 
by  a  healthy  ear,  for  the  simple  reason  that  different  watches 
may  be  heard  at  different  distances,  so  varying  is  the  distinct- 
ness of  the  tick.  It  may  be  approximately  stated,  however,  that 
an  ordinary  ticking  watch  should  be  heard,  by  a  person  with 
average  hearing  power,  at  least  four  feet.  To  this  rule  there 
are,  however,  many  exceptions.  For  instance.  I  know  a  medical 
gentleman  in  this  city,  who,  as  tested  by  the  ordinary  transac- 
tions of  professional  and  social  life,  is  not  at  all  hard  of  hearing, 
who  cannot  hear  a  watch  of  common  tone  more  than  six  inches. 

The  discrepancy  in  the  power  of  hearing  the  watch  and  or- 
dinary conversation,  as  was  shown  by  the  author  in  a  paper 
published  in  the  American  Journal  of  the  Medical  Sciences,  is 
so  marked  as  to  render  the  tick  of  a  watch  almost  useless  for 
determining  the  hearer's  power  in  many  cases.  Such  cases  as 
these,  I  have  since  learned,  are  invariably  due  to  disease  of  the 
internal  ear,  in  some  of  its  parts,  and  not  to  an  affection  of  the 
middle  ear.  This  discrepancy  is  one  of  the  means  of  differential 
diagnosis  between  affections  of  the  middle  and  internal  ear. 

In  testing  the  hearing  power  by  means  of  a  watch  it  is  well 
to  remember,  as  Von  Troltsch  suggests,  that  all  watches  are 
heard  better  immediately  after  they  are  wound,  and  also  that 
the  intensity  of  their  sound  is  increased  by  holding  them  so 
that  the  surgeon's  hand  covers  the  back,  or  when  they  are  held 
by  the  patient's  own  hand.  In  the  two  latter  instances  the  cause 
of  the  increased  clearness  of  the  tick  is,  in  the  one  case,  the  re- 
tardation of  the  reflection  of  sonorous  waves  from  the  watch, 
and  in  the  other,  the  conducting  power  of  the  patient's  own  arm 
as  it  is  stretched  out.  The  use  of  a  tape  or  other  measurer,  to 
note  the  number  of  inches  at  which  the  watch  is  heard,  is  indis- 
pensable for  an  accurate  record  of  a  case.  The  measure  should 


48  REGISTER    OF    HEARING    POWER. 

not  be  used,  however,  until  the  distance  has  been  ascertained 
without  it.  When  the  patient  cannot  hear  the  watch  at  any  dis- 
tance from  the  ear,  it  should  be  laid  or  pressed  upon  the  auricle, 
mastoid  process,  or  forehead.  Before  using  a  watch  for  the  pur- 
pose of  testing  the  hearing  power  of  diseased  ears,  we  should 
carefully  ascertain  how  far  it  may  be  heard  by  persons  whose 
hearing  is  unimpaired. 

Dr.  J.  S.  Prout,  Surgeon  to  the  Brooklyn  Eye  and  Ear  Hos- 
pital, has  greatly  facilitated  our  means  of  recording  the  hearing 
power,  by  a  simple  method,  which  is  somewhat  analogous  to  that 
used  in  estimating  the  acuteness  of  vision ;  but,  as  Dr.  Prout 
says  : '  "  The  accuracy  with  which  we  measure  the  visual  power 
by  Snellen's  test  types,  and  record  the  resulfs  obtained,  cannot 
be  arrived  at  by  means  of  any  of  the  usual  sound-makers  (sono- 
factors) ;  nor  will  it  be  until  an  instrument  can  be  made  which 
shall  always  produce  uniform  tones."  Dr.  Prout  recommends  a 
formula  for  registering  the  hearing  power,  which  he  describes 
as  follows  :  "For  nearly  three  years  I  have  recorded  the  hearing 
power  as  a  fraction,  the  numerator  of  which  is  the  distance  at 
which  the  particular  sound  is  heard,  the  denominator  the  dis- 
tance at  which  it  should  be  heard  by  an  ear  of  good  average 
hearing  power.  This  denominator  must  vary  according  to  the 
sonofactor  used,  and  should  generally  be  expressed  in  inches. 

"For  still  further  simplification,  and  that  the  method  may  be 
adapted  to  international  use,  I  suggest  the  following  abbrevia- 
tions :  A.  D. ,  auris  dextra,  instead  of  right  ear,  or  R.  E. ;  A.  S. ,  auris 
sinistra;  P.  A.,  P.  aud.,  potentia  auditus,  hearing  power;  V.,  vox, 
the  spoken  voice  ;  V.  S.,  vox  susurrata,  whispered  voice — or 
simply  S.,  susurrus,  a  whisper;  H.,  horologium,  the  watch. 

"  If  the  system  should  become  general,  then  the  formula 
P  A,  A  D,  H,  =  J$,  would  to  all  otologists  represent  the  fact  that 
a  watch  that  should  be  heard  at  36  inches  was  heard  by  the 
right  ear  of  the  patient  at  a  distance  of  12  inches  ;  the  formula 
P  A,  A  S,  V  S,  =  •&,  would  mean  that  the  whispered  voice  was 
heard  by  the  left  ear  at  6  inches  that  should  have  been  heard  at 
36  inches." 

Dr.  Prout's  method  is  now  universally  employed.  If  a  watch 
can  be  heard  by  a  person  with  good  hearing  power  at  least  48 
inches,  and  we  wish  to  express  the  hearing  power  of  a  person 
who  hears  that  watch  one  inch,  we  use  the  fraction  -fa,  and  so 
on.  If  the  patient  only  hears  the  watch  when  brought  in  contact 
with  the  ear,  we  may  employ  the  formula  •£% ;  if  only  on  pressure, 
•£$ ;  if  not  at  all,  -fe ;  if  on  the  mastoid,  j\. 

The  objects  to  be  gained  by  testing  the  hearing  power  are,  of 

1  Boston  Medical  and  Surgical  Journal,  February  29,  1872. 


TEST  BY   WATCH  AND   CONVERSATION. 


49 


course,  to  learn  when  a  patient  is  first  seen  how  much  his  hear- 
ing power  is  impaired,  and  as  he  continues  under  treatment 
whether  or  not  any  improvement  has  taken  place.  If  the  watch 
alone  be  used  for  this  purpose,  there  are  many  opportunities  for 
error  in  opinion.  For  example,  some  patients,  especially  chil- 
dren, readily  imagine  they  hear  the  ticking  of  a  watch  when 
they  do  not.  Adults  who  are  very  much  troubled  by  tinnitus 
aurium  also  fall  into  this  kind  of  error.  In  testing  one  ear  with 
the  watch  we  should  be  careful  to  exclude  the  other,  for  sound 
readily  passes  through  the  bones  of  the  head,  or  the  air,  or  both, 
to  the  other  ear.  Especially  is  this  the  case  when  one  ear  is  so 
much  affected  that  it  is  only  heard  when  pressed  upon  the  mastoid 
process  (¥^),  or  not  at  all  (£$).  I  think  it  is  true  that  patients 
affected  with  certain  forms  of  disease  of  the  acoustic  nerve, 
hear  a  watch  relatively  much  worse  than  they  do  conversation. 


Table  showing  the  Disproportion  between  the  Power  of  Hearing 
the  Tick  of  a  Watch  and  the  Human  Voice.1 


No. 

Sex  and  age. 

Hearing  distance  for  the  watch. 

Hearing  distance  for  conversation,  the  pa- 
tient being  with  the  back  to  the  speaker. 

1 

Female,  17. 

Elaid     T         0 
•  TIT'  •"•  TO"' 

Words  spoken  loudly  at  10  feet 

with  difficulty. 

RJL    T,     0 
To>  *•*•  ¥0"' 

Loud  conversation  at  20  feet. 

2 

Male,  45. 

B.  A»  L  A- 

Voice  at  30  feet  ;  cannot  tell  the 

direction    from   which    sound 

comes. 

3 

Female,  28. 

B.  A>  L-  A 

Conversation  at  20  feet. 

4 

Male,-  56. 

R  laid,  L.  laid. 

Conversation  at  20  feet. 

5 

Male,  62.      R  pressed,  L.  pressed. 

Loud  conversation  at  20  feet. 

6 

Female,  23. 

B-  A*  -"-*.  A- 

Loud  conversation  at  6  feet. 

7 

Male,  9£. 

B.  A»  L.  A- 

Loud  conversation  at  30  feet 

8 

Male,  16. 

Elaid     T.     laid 
•  To>  **  To"' 

Conversation  at  20  feet. 

9 

Male,  18. 

"R     40      T,      34 
•"•    40'    "'-'•    40* 

Conversation  at  12  feet. 

E4.0     T.    40 
•  XTfj    ^'    A  Q  * 

Conversation  at  30  feet. 

10 

Female,  15. 

B.  A'  •'-'•  A' 

Conversation  at  20  feet. 

11 

Male,  19. 

K.  A,  L.  H- 

Conversation  at  20  feet. 

12 

Female,  29. 

Rlaid     T       laid 
To"'          TO" 

Conversation  at  20  feet. 

13 

Male,  40. 

H.  D.  R  A,  L-  {ft 

Ordinary  conversation  with  great 

ease  at  30  feet. 

14 

Female,  25. 

B.  if,  L.  A 

Ordinary  conversation  with  diffi- 

culty at  20  feet. 

15 

Male,  32. 

R  A,  L.  i#  . 

Conversation  at  16  feet. 

16 

Male,  15. 

R.  A>  ^-  niastoid. 

Conversation  at  20  feet. 

17 

Male,  41. 

B.  A'  L-  A- 

Conversation  with  ease  at  40  feet 

1  American  Journal  of  the  Medical  Sciences,  Vol.  Ixxiii. ,  p.  50. 
4 


50 


TICK   OF  A   WATCH. 


Table  showing  the  Disproportion  between  the  Power  of  Hearing 
the  Tick  of  a  Watch  and  the  Human  Voice. — (Continued.) 


No. 

Sex  and  age. 

Hearing  distance  for  the  watch. 

Hearing  distance  for  conversation,  the  pa- 
tient being  with  the  back  to  the  speaker. 

18 

Male,  45. 

R  ^,  L.  ^ys. 

Conversation  at  40  feet. 

19 

Male,  54. 

R  ri,,  L.  «n*. 

Loud  conversation  at  45  feet. 

20 

Male,  70. 

R  i---  L.  Jft 

Conversation  at  30  feet. 

21 

Female,  16. 

R.  43o>  L.  & 

Voice  with  difficulty  at  10  feet. 

22 

Male,  80. 

B.  A,  L-  jfr 

Conversation  at  40  feet. 

23 

Male,  32. 

R.  A*  L  A- 

Conversation  at  30  feet. 

24 

Male,  36. 

•R     contact     T        mastoid 

J*  -iir>  **  ~  *  o~- 

Ordinary  conversation  at  18  feet. 

25 

Female,  24. 

R.  A.  L-  A- 

Conversation  at  10  feet. 

26 

Male,  74. 

R  ^  L-  A- 

Conversation  at  50  feet. 

27 

Female,  15. 

R.  42«  ,  L-  A- 

Ordinary  conversation  at  40  feet. 

28 

Male,  71. 

R  tf,  L.  1^. 

Conversation  at  20  feet. 

29 

Male,  44. 

R.  *fc  L.  #. 

Conversation  at  30  feet. 

30 

Female,  22. 

R.  tf,  L.  A 

Conversation  at  26  feet. 

After  removal  of  ceru- 

men and  inflation. 

Conversation  at  30  feet. 

31 

Male,  38. 

R  £,  L.  pressed. 

Conversation  at  20  feet. 

32 

Male,  13. 

"R    5.5    ]      J_ 
**•  3  o>  •1J'  ¥o- 

Conversation  at  30  feet. 

33 

Male,  21. 

Rl        T      pressed 
10'    "      TO"' 

Loud  conversation  at  8  feet. 

34 

Male,  33. 

R.  SS,  L.  ?v 

Conversation  at  50  feet  ;  general 

conversation   with  ease  ;   does 

not  hear  high  notes  well. 

35 

Female,  17. 

K.  A.  L.  A- 

Conversation  with  some  difficulty 

at  30  feet. 

36 

Female,  34. 

R  1^,  L.  5» 

Loud  conversation  at  6  feet. 

37 

Female,  37. 

B.  A,  L.  j#. 

Distinct  voice  at  2  feet. 

38 

Female,  36.            K.  £«*,  L.  £$. 

Voice  at  34  feet  after  use  of  arti- 

After use  of  artificial 

ficial  membranse  tympanorum. 

membranes,  R  T\,  L.  ^. 

The  tick  of  a  watch  is  produced  by  the  striking  of  a  little 
hammer  upon  the  apex  or  side  of  the  tooth  of  a  ratchet-wheel. 
It  is  therefore  a  simple  unvarying  tone,  modified  as  to  quality 
in  different  watches.  Now  the  sounds  produced  by  the  vocal 
cords,  reinforced  by  the  resonating  cavities  of  the  nose  and 
mouth,  may  pass  through  a  range  of  musical  notes,  which,  as  in 
the  case  of  the  late  Madame  Parepa  Rosa,  may  compass  three 
full  octaves.  A  mere  regular  sound,  such  as  that  of  the  watch, 
is  certainly  in  no  sense  to  be  compared  to  the  musical  tones  of 
that  wonderful  instrument  the  human  larynx.  If,  however,  the 
power  of  hearing  the  watch  tick  stood  in  any  definite  and  fixed 
relation  to  the  ability  to  hear  ordinary  conversation,  it  would 
serve  very  well  as  a  test  for  registration.  If,  for  example,  we 


VON  CONTA'S  METHOD.  51 

were  able  to  say  that  a  person  who  has  a  hearing  distance  by 
the  watch  of  f$,  has  a  degree  of  hearing  sufficient  for  the  duties 
of  life,  that  it  is  as  adequate  as  f -g-  as  tested  by  Snellen's  test- 
types  is  for  seeing,  the  statement  would  give  us  a  definite  idea 
of  just  how  much  the  hearing  power  is  impaired.  But  a  refer- 
ence to  the  table  shows  that  the  power  of  hearing  the  tick  of  a 
watch  stands  in  no  exact  proportion  to  the  power  of  hearing  con- 
versation. On  the  othef  hand,  the  test  by  the  voice  is  also  in- 
adequate. When  a  person  is  waiting  to  hear  a  voice  in  a  quiet 
room,  his  ability  to  hear  this,  when  compared  with  what  is  de- 
manded of  an  ear,  is  utterly  inadequate  as  a  test.  As  is  well 
known,  a  healthy  ear  can  appreciate  from  seven  to  eleven  oc- 
taves. Probably  the  life  we  lead  in  large  cities  and  towns  re- 
quires such  a  power  if  we  are  to  hear  all  that  is  demanded  of  us. 
How  then  can  the  tones  of  the  larynx,  capable  at  its  greatest  of 
reaching  three  octaves,  form  a  sufficient  test  ? 

Again,  as  will  be  shown  in  a  subsequent  chapter,  a  whole 
class  of  persons  suffering  from  disease  of  the  ears  hear  better  in 
a  noise,  while  another  class  hear  best  in  quiet  places.  All  these 
things  must  be  taken  into  consideration  in  testing  the  hearing 
power  or  erroneous  conclusions  will  often  be  reached.  Unre- 
liable as  are  the  statements  of  patients  as  regards  the  history  of 
their  cases,  their  testimony  as  to  their  improvement  or  non- 
improvement  is  always  of  value  in  determining  the  true  state  of 
the  hearing  power,  and  better  still  are  the  statements  of  their 
relatives  or  friends,  who,  no  matter  how  great  their  affection, 
are  always  annoyed  by  being  obliged  to  make  an  effort  to  make 
them  hear.  They,  at  least,  will  gladly  hail  and  note  any  greater 
ability  to  hear  on  the  part  of  a  person  with  whom  they  have 
been  in  the  habit  of  conversing. 

THE   TUNING-FORK. 

The  value  of  the  tuning-fork  in  testing  the  hearing  power  is 
chiefly  in  the  way  of  determining  whether  a  given  disease  be  in 
the  middle  or  internal  ear.  Von  Conta,1  of  Weimar,  recom- 
mended it  some  years  since,  however,  as  a  means  of  testing  the 
hearing  power.  In  his  method,  the  vibrations  from  the  tuning- 
fork  are  conducted  to  the  ear  through  an  elastic  tube.  The  num- 
ber of  seconds  during  which  the  gradually  decreasing  vibrations 
are  heard  becomes  the  measure  of  the  hearing  power.  This 
method  never  found  any  great  favor,  and  so  far  as  I  know  is  not 
often  employed. 


1  Archiv.  fur  Ohrenlieilkunde,  Bd.  L,  p.  108. 


52  THE   TUNING-FORK. 

Since  then,  however,  the  tuning-fork  has  been  and  continues 
to  be  widely  employed  in  various  ways  for  the  purpose  of  differ- 
ential diagnosis.  I  believe  we  now  have  in  it,  by  a  very  simple 
method,  a  valuable  aid  to  a  knowledge  of  the  situation  of  a 
given  lesion.  I  shall,  however,  before  describing  the  method 
I  now  employ  to  the  exclusion  of  all  others  in  the  test  with  the 
tuning-fork,  first  give  an  account  of  the  history  of  its  use  in 
aural  diagnosis,  with  a  statement  of  the.  methods  in  which  it  is 
generally  used. 

As  is  well  known,  if  we  close  our  ears,  and  speak,  the  sound 
of  the  voice  seems  to  be  confined  to  the  head,  as  it  were  ;  its  re- 
flection being  to  a  certain  extent  prevented  by  the  closure  of  the 
external  auditory  canal.  If  now  the  auditory  nerve  be  sound, 
and  there  be  impacted  wax  in  one  auditory  canal,  or  a  thicken- 
ing of  the  mucous  membrane  lining  the  cavity  of  the  tympanum, 
the  state  of  things  will  be  similar  to  that  when  the  external 
meatus  of  a  healthy  ear  is  closed  by  the  finger,  or  by  some  simi- 
lar means,  and  the  vibration  of  a-  tuning-fork  placed  upon  the 
bones  of  the  head  will  be  heard  more  distinctly  by  an  ear  thus 
affected  than  by  the  sound  one.  If  the  ears  are  equally  affected, 
it  will  be,  of  course,  more  difficult  to  come  to  a  conclusion.  If 
the  nerve  be  seriously  impaired,  from  a  primary  lesion,  or  secon- 
darily, by  disease  which  has  extended  from  the  middle  ear,  no 
such  marked  difference  will  be  noticed  when  the  external  meatus 
is  closed. 

Again,  when  the  tick  of  a  watch  cannot  be  heard  at  all,  if 
the  auditory  nerve  be  not  seriously  impaired,  the  vibrations  of 
the  tuning-fork,  when  its  handle  is  placed  on  the  teeth,  fore- 
head, or  mastoid  process,  will  be  distinctly  heard  ;  while  if  the 
nerve  be  the  seat  of  serious  lesion,  so  that  absolute  deafness 
exists,  these  vibrations  will  not  be  at  all  perceived  in  the  head. 
Some  deaf-mutes,  who  were  born  deaf,  and  perhaps  with  a  dis- 
ease of  the  central  apparatus,  have  assured  me  that  they  always 
felt  the  sound  of  the  tuning-fork  passing  to  the  region  of  the 
diaphragm  or  stomach,  and  they  would  involuntarily  place  their 
hand  there  when  the  vibration  began.  The  large  tuning-forks 
of  the  note  C  are  to  be  preferred  to  the  smaller  ones. 

There  is  one  source  of  error  in  the  use  of  the  tuning-fork  in 
this  manner  that  cannot  be  fully  avoided.  Patients  who  do  not 
possess  fair  habits  of  observation  will  say  that  they  hear  the  tun- 
ing-fork better  from  the  better  ear,  because  they  think  that 
they  ought  to  do  so.  A  little  care  in  urging  such  persons  to 
notice  the  sound  carefully  will  usually  cause  a  correct  answer 
to  be  given.  Its  chief  value  is,  however,  among  persons  who 
can  be  taught  to  observe  what  they  actually  hear,  and  who 


THE  TUNING-FORK.  53 

will  allow  their  theoretical  notions  to  remain  in  abeyance  for  a 
time. 

The  following  case  illustrates  the  old  method  of  using  the 
tuning-fork  as  a  means  of  diagnosis,  and  also  the  inadequacy 
of  the  watch  as  a  test  of  hearing  : 

Dr.  W ,  aged  thirty-three,  consulted  me  in  regard  to  an 

uncomfortable,  "stuffy"  sensation  in  the  right  ear,  attended  by 
a  slight  impairment  of  hearing.  His  history  was  that  he  had 
had  nasal  catarrh  for  some  months ;  for  two  days  he  has  ob- 
served the  aural  trouble.  On  testing  the  hearing  power  by  the 
watch  it  was  found  to  be  normal,  or  £ |,  on  both  sides  ;  but  the 
tuning-fork  was  heard  better  on  the  affected  side,  and  the  pa- 
tient, a  busy  physician  and  an  exact  observer,  was  sure  that 
his  hearing  power  was  somewhat  impaired  upon  the  right  side, 
although  the  watch  did  not  detect  it.  The  membrana  tympani 
was  slightly  injected  along  the  handle  of  the  malleus. 

I  diagnosticated  the  affection  as  sub-acute  inflammation  of 
the  middle  ear  of  the  right  side,  and  treated  it  by  the  use  of  the 
Eustachian  catheter,  Politzer's  method,  and  a  gargle,  as  well  as 
by  the  application  of  a  leech  to  the  tragus.  After  the  first  use 
of  the  catheter  and  Politzer's  method,  the  tuning-fork  was  heard 
with  equal  distinctness  on  both  sides,  thus  confirming  the  diag- 
nosis and  illustrating  the  value  of  the  test.  The  patient  re- 
covered perfectly  in  a  few  days  ;  but  at  each  visit  before  the  ear 
was  inflated  until  his  ear  was  fully  restored  to  the  normal  con- 
dition, the  tuning-fork  was  heard  more  distinctly  on  the  affected 
side. 

As  has  been  previously  intimated,  I  no  longer  employ  the 
tuning-fork  in  this  manner  for  the  purpose  of  making  a  diag- 
nosis, but  I  rely  upon  the  statements  of  the  patient  as  to  whether 
the  tuning-fork  is  heard  more  distinctly  and  for  a  longer  time 
when  its  vibrations  are  conducted  through  the  air  or  through  the 
bones  of  the  head.  It  is  much  easier  for  any  person  to  determine 
whether  he  hears  a  tuning-fork  when  held  in  front  of  the  ear 
better  or  worse  than  he  does  when  it  is  placed  on  the  mastoid 
process,  than  it  is  for  him  to  say  on  which  side  of  the  head  he 
hears  it  better.  It  is  consequently  a  step  toward  an  objective 
test,  if  not  one  itself,  if  the  distinction  which  we  ask  the  patient 
to  make  is  one  so  easily  made  that  even  an  ignorant  person  can 
make  it.  It  is,  I  believe,  perfectly  easy  for  even  a  stupid  per- 
son to  determine  which  of  two  sounds  is  the  louder  if  there  be 
any  appreciable  difference  between  them.  This  is  the  whole 
problem  to  be  solved  in  determining  the  difference  between 
conduction  by  air  and  by  bone.  This  subject  will  be  more 
fully  discussed  in  the  chapter  devoted  to  diseases  of  the  in- 


54  AERIAL    AND    BONE   CONDUCTION. 

ternal  ear.  Here  it  will  be  sufficient  to  indicate  the  method  of 
testing. 

A  tuning-fork  "  C2  "  (according  to  Helmholtz  C2= 528  vibra- 
tions) is  heard  better  by  persons  with  normal  hearing  when  held 
while  vibrating  in  front  of  the  entrance  to  the  external  auditory 
canal — that  is,  it  is  heard  louder.  It  is  also  heard  longer.  This 
is  also  true  of  other  forks,  but  for  the  sake  of  clearness  the  re- 
marks here  made  are  confined  to  the  C2  tuning-fork.  At  my 
request,  Dr.  J.  B.  Emerson,  Surgeon  to  the  Manhattan  Eye  and 
Ear  Hospital,  undertook  some  experiments,  which  show  these 
statements  to  be  correct. ' 

Starting  from  such  observations  upon  healthy  ear,  we  find 
that  in  disease  of  the  external  or  middle  ear  the  intensity  with 
which  the  tuning-fork  is  heard  through  the  bones  is  increased. 
In  other  words,  the  natural  relations  between  conduction  through 
the  air  and  through  the  bones  is  disturbed.  The  bone  conduction 
is  better  than  the  aerial.  It  has  also  been  ascertained  by  many 


FIG.  1.— Tuning-fork. 

examinations  that  the  diagnosis  of  disease  of  the  middle  or  ex- 
ternal ear  may  always  be  made  when  the  bone  conduction  is 
increased  in  intensity  and  relatively  in  duration.  On  the  other 
hand,  in  a  case  of  impaired  hearing  with  a  loss  of  bone  conduc- 
tion, while  the  conduction  through  the  air — aerial  conduction- 
remains,  we  know  that  we  are  dealing  with  an  affection  of  the 
labyrinth  or  acoustic  nerve.  We  may  formulate  the  propositions 
as  follows  : 

I.  If  the  hearing  be  impaired,  and  we  find  the  aerial  conduc- 
tion better  than  that  through  bone,  we  are  dealing  with  disease 
of  some  part  of  the  acoustic  nerve,  which  may  be  either  pri- 
mary or  secondary  to  disease  of  the  middle  ear. 

II.  If  the  conduction  through  the  bone  be  intensified  and  last 
longer  in  time  than  the  aerial  conduction,  our  case  is  one  of  dis- 
ease of  the  middle  or  external  ear.     Of  course,  if  the  case  be  one 
of  impacted  cerumen  or  other  disease  of  the  external  ear,  it  is  at 
once  diagnosticated  by  an  examination,  and  the  test  by  the  tun- 
ing-fork is  practically  useless,  but  it  becomes  very  valuable  in 
cases  where  we  are  in  doubt  as  to  whether  disease  of  the  middle 


1  Archives  of  Otology,  vol.  xv. ,  No.  1. 


AERIAL   AND   BONE   CONDUCTION.  5.5 

or  internal  ear  exists,  if,  as  I  believe,  after  much  experience,  it 
be  one  that  can  be  depended  upon.  The  method  of  making  the 
test  is  extremely  simple.  The  tuning-fork  is  placed  in  vibration 
by  being  struck  on  the  knee  of  the  examiner.  It  is  then  held  in 
front  of  the  meatus  to  test  the  vibrations  through  the  air,  and 
is  again  set  in  vibration  and  its  handle  placed  on  the  mastoid 
process  about  in  its  centre  to  test  the  conduction  by  bone. 

In  testing  the  duration  of  the  conduction  by  air  (aerial  con- 
duction) or  by  bone,  a  stop-watch  is  essential  for  accuracy.  'The 
patient  indicates  the  moment  he  ceases  to  hear  the  vibrations 
by  lifting  the  hand.  I  am  well  aware  of  the  criticisms  made 
against  this  method  of  examination,  that  it  is  entirely  subjec- 
tive, that  it  leaves  too  much  to  the  patient's  intelligence  and 
truthfulness,  and  so  forth.  To  these  and  similar  objections  I 
can  only  answer  that  those  who  give  this  method  of  using  the 
tuning-fork  a  fair  trial  will,  I  am  sure,  find  that  it  is  an  ex- 
tremely valuable  test.  In  my  opinion  the  test  by  aerial  and 
bone  conduction  will,  if  tried,  supersede  all  the  methods  of  ex- 
amination by  the  tuning-fork  as  yet  known. 

The  tuning-fork  is  heard  better  through  the  bone  in  disease 
of  the  middle  ear  because  of  the  increased  resonating  capacity 
of  these  parts  when  diseased  by  increase  of  tissue.  When,  on 
the  other  hand,  there  is  disease  of  the  acoustic  nerve,  the  sound 
is  heard  most  distinctly  and  longer  when  it  passes  through  the 
best  channel — that  is,  through  the  external  auditory  canal,  the 
tympanic  cavity,  and  the  fenestra  ovalis. 

When  an  affection  of  the  middle  ear  exists  which  cannot  be 
detected  by  the  watch  or  by  conversation,  although  said  to  exist 
by  the  patient,  it  will  be  found  that  the  tuning-fork  will  con- 
firm the  patient's  statements  that  one  ear  "  is  not  right ;"  that 
is,  the  bone  conduction  will  be  longer  and  more  intense  than 
the  aerial ;  and  a  thorough  inflation  will  often  restore  the  nor- 
mal relations.  The  objections  that  have  been  made  as  to  the 
value  of  the  tuning-fork  as  a  means  of  assisting  in  a  differential 
diagnosis,  are  chiefly  against  the  old  method  of  determining  on 
which  side  the  tuning-fork  is  heard  better.  Yet  even  when  used 
in  this  way  it  is  valuable,  although  as  I  trust,  it  is  soon  to  be 
superseded  by  the  simple  tests  of  the  intensity  and  duration  of 
aerial  and  bone  conduction. 

According  to  Politzer,1  E.  H.  Weber  was  the  first  to  show 
the  facts  that  have  been  stated  with  regard  to  the  increase  in 
intensity  of  the  sound  of  a  tuning-fork  on  the  side  of  the  meatus 
that  is  closed  by  the  finger.  Mach,  quoted  by  Politzer,  ex- 
plained this  fact  by  the  theory  that  the  reflections  of  the  waves 

1  Reprint  from  Wiener  Medizinischen  Wochenschrift. 


56  THEORY   OF   TEST   BY   TUNING-FORK. 

of  sound  from  the  ear  was  prevented  by  this  closure  of  the 
auditory  canal.  Politzer  concludes,  as  the  result  of  experi- 
ments, which  may  be  found  in  detail  in  the  first  volume  of  the 
"  Archiv  fur  OhrenheiLkunde,"  that  the  increased  perception  of 
sound  that  is  felt  in  one  ear  depends  upon  two  causes  : 

1.  The  waves  of  sound  that  have  been  carried  from  the  bones 
of  the  skull  to  the  air  of  the  external  auditory  canal  are  reflected 
back  on  the  membrana  tympani  and  ossicula  auditus. 

2.  In  accordance  with  Mach's  theory,  the  passing  out  of  the 
waves  of  sound  which  have  reached  the  labyrinth  and  cavity  of 
the  tympanum,  through  the  bones  of  the  head,1  is  prevented  by 
the  obstacle  they  meet  in  the  closed  ear. 

It  will  thus  be  seen  that  Mach  and  Politzer  explain  the  phe- 
nomenon of  increased  perception  of  sounds  conveyed  through 
the  skull,  in  an  ear  whose  peripheric  portions  are  obstructed  by 
disease,  or  by  some  mechanical  cause,  entirely  by  the  theories 
that  the  loss  of  sound  is  prevented  by  the  obstruction  to  its  re- 
flection from  the  auditory  canal,  and  that  the  force  of  the  waves 
is  also  intensified  by  their  being  thrown  back  upon  the  nerve. 

Even  if  we  do  not  now  employ  the  tuning-fork  by  determin- 
ing on  which  side  of  the  head  it  is  heard  better,  the  explanations 
as  to  the  interesting  phenomena  revealed  by  such  a  test  are  not 
without  value,  and  they  are  accordingly  given.  If,  in  a  decided 
case  of  catarrh  of  the  middle  ear,  the  tuning-fork  is  heard  better 
on  the  normal  side,  we  must  conclude  that  there  is  some  lesion 
of  the  labyrinth — perhaps  as  Politzer a  and  Schwartze  suggest, 
"  a  fluxion  toward  the  labyrinth  with  serous  exudation  in  the 
nerve  structure."  In  cases  of  this  kind,  as  the  pressure  upon 
the  labyrinth  is  removed  by  a  decrease  of  the  catarrh  of  the 
middle  ear,  the  tuning-fork  will  be  heard  better  on  the  affected 
side. 

Politzer '  explains  the  fact  that  in  some  cases  of  perforation 
of  the  membrana  tympani,  the  tuning-fork  is  heard  better  on 
the  affected  side  by  two  reasons  : 

1.  The  mobility  of  the  ossicula  auditus,  by  which  the  passage 
outward  of  the  waves  of  sound  that  have  once  reached  the  laby- 
rinth is  retarded,  is  lessened. 

2.  By  the  perforation  of  the  drum-head,  the  cavity  of  the 
tympanum  and  auditory  canal  are  converted  into  one  space, 
and  a  greater  resonance  from  the  larger  air-chamber  is  pro- 
duced, which  acts  upon  the  fenestrce  ovalis  and  rotunda,  and 
increases  the  intensity  of  the  perceptive  power  of  the  labyrinth. 

1  Archiv  fur  Ohrenheilkunde,  B.  I.,  p.  321,  1868.     Politzer,  loc.  cit. 
*  Loc.  cit.,  p.  5.  3  Loc.  cit.,  p.  12. 


BLAKE'S  TUNING-FORK. 


57 


The  tuning-fork  used  by  Politzer  in  his  experiments  and  in 
his  practice  corresponds  to  the  second  C  in  the  base,  vibrating 
512  times  in  the  second.  On  striking  it,  we  notice  particularly 
two  distinct  tones — one  the  ground  tone  .or  dominant,  the  other 
the  upper  tone  or  musical  fifth  ;  either  one  or  the  other  pre- 
dominates, according  to  the  density  of  the  substance  against 
which  the  tuning-fork  is  struck.  In  employing  it  for  diagnosis, 
the  predominance  of  the  upper  tone  is  often  very  confusing  to 
the  patient,  and  the  cause  of  error. 

In  order  to  get  the  pure  dominant,  it  is  only  necessary  to 
affix  a  pair  of  metal  clamps  to  the  ends  of  the  branches  ;  this  is 
done  by  means  of  small  screws.  If  the  tuning-fork  is  now 
struck  even  with  a  hard  substance,  only  the  dominant  is  percep- 
tible. Dr.  Schaar,1  of  Vienna,  diminishes  the  intensity  of  the 
upper  tone  by  gentle  pressure  upon  the  lower  por- 
tion of  the  branches.  The  value  of  the  tuning-fork 
in  testing  the  perception  of  different  musical  tones 
has  been  much  increased  by  the  discovery  that, 
by  fixing  the  clamps  at  different  points  upon  the 
branches,  it  is  possible  to  obtain  all  the  tones  and 
semitones  up  to  an  octave  above  the  musical 
fourth  of  the  dominant  tone  of  the  tuning-fork.— 

{POLITZER.) 

Dr.  Blake/  who  has  written  a  good  digest  of 
this  subject,  says  that  "  Itard  used  a  bell  which 
was  struck  by  a  pendulum,  the  force  of  the  blow 
being  determined  by  the  space  through  which  the 
pendulum  passed  before  striking  ;  in  this  way  the 
difficulty  as  to  control  of  the  intensity  of  the  sound 
was  overcome,  but  the  tone  remained  the  same." 
Following  this  idea,  Dr.  B.  caused  to  be  constructed 
the  tuning-fork  as  represented  in  the  accompany- 
ing woodcut  (one-third  size),  that  is,  the  common 
instrument  with  the  clamps  as  used  by  Dr.  Polit- 
zer, but  with  the  addition  of  a  hammer,  the  head 
of  steel,  one  face  being  covered  with  soft  rubber. 
"  Lucae  proposed  the  use  of  a  hammer  faced  with 
some  elastic  material  for  striking  the  tuning-fork. 
The  handle  of  the  hammer  is  a  steel  spring,'  sliding  in  a  bar  af- 
fixed to  the  stem  of  the  fork,  and  fastened  in  place  by  a  small  set 
screw.  By  using  either  the  steel  or  rubber  face  of  the  hammer, 
either  the  upper  or  lower  tone  will  be  rendered  most  prominent. 


Fia.   2.— Blake's 
Tuning-fork. 


'Blake  :  Reprint  from  Boston  Medical  and  Surgical  Journal,  p.  3. 
s  Blake,  loc.  cit. 


58  ENTOTIC   USE   OF   SPEAKING-TUBE. 

By  affixing  the  clamps  as  Politzer  directs,  we  obtain  the  variety 
of  tone,  and  by  the  distance  to  which  the  hammer  is  sprung  can 
regulate  their  intensity.  The  adjustment  is  simple,  and  obviates 
the  necessity  of  employing  any  other  musical  instrument." 

In  cases  of  disease  of  the  auditory  nerve,  it  is  often  of  in- 
terest to  test  the  capacity  of  the  patient  for  hearing  high  or  low 
tones.  For  this  purpose  I  use  a  piano,  connecting  the  ear  of  the 
patient  to  the  keys  by  means  of  a  flexible  stethoscope.  Politzer ' 
uses  an  harmonium,  in  the  casing  of  which  is  an  opening,  for 
the  insertion  of  the  auscultation  tube. 

Dr.  Bing  makes  what  he  terms  an  entotic  application  of  the 
hearing-trumpet  as  a  means  of  diagnosis.  In  practising  Bing's 
method,  words  are  spoken  into  the  mouth  of  a  hearing-trumpet, 
the  other  end  of  which  is-  directly  connected  with  the  cavity  of 
the  tympanum  by  being  inserted  into  the  nozzle  of  a  Eusta- 
chian  catheter,  whose  extremity  lies  in  the  Eustachian  tube. 
The  waves  of  sound  pass  through  the  hearing-trumpet  and 
catheter  directly  to  the  base  of  the  stapes  bone,  and  are  thus 
transmitted  to  the  terminal  filaments  of  the  acoustic  nerve.  In 
a  case  in  which  speech  cannot  be  at  all  understood  through  a 
hearing-trumpet,  but  is  heard  by  its  application  to  the  interior 
of  the  tympanum,  we  may  conclude  that  the  hindrance  to  the 
conduction  of  sound  is  in  the  malleus  or  incus,  while  the  mobility 
of  the  base  of  the  stapes  is  not  impaired.4 

For  a  full  account  of  Lucre's  interference  otoscope  or  apparatus  see  previous  edi- 
tions of  this  work.  I  have  omitted  it  in  this  edition,  since  it  seems  to  me  that  all  the 
tests  by  the  tuning-fork  except  the  simple  one  have  become  unnecessary. 

MALINGERING. 

In  countries  where  liability  to  military  service  is  universal, 
there  are  many  malingerers,  who  claim  to  be  dull  of  hearing  in 
one  or  both  ears.  Next  in  frequency,  it  is  claimed  that  there  is 
absolute  deafness  of  one  ear  only.  It  is  so  difficult  to  maintain 
for  any  length  of  time  a  false  assertion  of  absolute  deafness  of 
both  ears,  that  it  is  seldom  attempted.  The  only  malingerers  that 
I  have  seen  in  our  country  since  the  close  of  the  civil  war,  have 
been  found  among  the  applicants  for  the  pensions  that  our  Gov- 
ernment gives  with  such  liberality  to  those  who  were  in  any 
way  disabled  while  in  the  national  service.  Dr.  David  Coggin's 3 
method  of  testing  a  patient  who  states  that  he  is  deaf  of  one 

1  Text-book,  p.  167. 

8  Politzer  :   Lehrbuch,  S.  215.     Translation,  p.  186. 

'Archives  of  Otology,  Vol.  viii.,  p.  177. 


COGGIN'S  TEST.  59 

ear  is  simple  and  valuable.  He  uses  a  Camman's  bin-aural 
stethoscope.  He  plugs  the  right  metal  socket  with  a  wooden 
stopper  if  the  patient  claims  to  be  deaf  of  the  left  ear.  On  using 
the  stethoscope  in  this  manner  for  hearing  speech,  a  person  with 
good  hearing  power  will  find  that  he  cannot  distinguish  it  with 
the  right  ear.  The  person  who  claimed  to  be  deaf  of  the  left 
ear,  was  first  tested  while  the  tube  of  the  right  arm  was  plugged, 
and  it  was  found  that  he  could  hear  a  whisper  in  the  thoracic 
cup,  which  served  as  a  mouth-piece..  The  tube  containing  the 
plug  was  then  removed,  and  the  tragus  was  firmly  pressed 
against  the  meatus,  so  as  to  completely  close  it.  Then  the  tube 
was  applied  to  the  left  ear,  as  before  ;  the  patient  positively  de- 
nied that  he  could  hear  what  Dr.  Coggin  said  to  him.  He  knew 
that  the  tube  through  which  he  supposed  he  heard  before  was 
no  longer  in  the  right  ear.  As  has  been  said,  simulation  of  im- 
pairment of  hearing  on  both  sides  is  very  difficult  to  detect. 
Such  a  person  should  be  kept  under  observation  for  some  few 
days,  and  repeated  examinations  made  as  the  ingenuity  of  the 
surgeon  may  suggest  them. 

EXAMINATION  OF  AUDITORY  CANAL  AND  MEMBRANA  TYMPANI. 

The  next  step  after  noting  the  hearing  power  in  the  examina- 
tion of  our  imaginary  patient,  is  the  exploration  of  the  auditory 
canal  and  the  membranse  tympani. 


FIG.   o. — Angular  forceps. 

It  is,  of  course,  implied  in  this  that  an  affection  of  the  auricle 
needs  no  special  assistance  for  examination. 

For  the  purpose  of  examining  the  external  auditory  canal 
three  instruments  may  be  necessary  :  a  pair  of  angular  forceps, 
an  aural  speculum,  and  a  concave  mirror  or  reflector.  The  first 
is  of  use  to  remove  any  temporary  obstructions  which  may  pre- 
vent a  view  ;  the  second  dilates  the  canal ;  and  the  third  throws 
the  light  into  it. 


60  SPECULA. 

According  to  Wilde,1  Dr.  Newbourg,  in  a  memoir  published 
at  Brussels  in  1827,  recommended  an  instrument  which  is  the 
origin  of  all  the  tubular  ear  specula  now  in  use.  It  was  a  slender 
horn  tube,  four  inches  long,  with  a  bell-shaped  outer  orifice. 
Subsequently  this  instrument,  which  was  much  too  long,  was 
improved  by  shortening  it,  by  Dr.  Ignaz  Gruber,  of  Vienna,  and 
generally  introduced  to  the  profession  by  Sir  William  Wilde  in 
1844.  After  a  fair  trial  of  the  bi-valvular  instrument  of  Kramer, 
and  the  funnel-shaped  one  of  Toynbee,  I  now  use  the  conical 
speculum,  either  that  of  Wilde,  Troltsch,  or  Gruber.  I  do  not 
think  that  any  one  of  these  has  any  great  advantage  over  the 
others.  The  practitioner  will  do  very  well  with  any  one  of  them. 
Too  much  stress  is  sometimes  laid  on  a  little  change  in  shape. 
I  prefer  that  the  interior  surface  of  the  speculum  be  brilliant, 
and  not  black,  as  those  of  Gruber  are  sometimes  made. 

Those  who  consider  that  there  is  an  advantage  in  a  funnel- 
shaped  instrument  will  find  the  one  here  figured  preferable  to 


FIG.  4. — Gruber's  Speculum. 

Toynbee's,  because  the  transition  from  the  wide  orifice,  which 
dilates  the  cartilaginous  part  of  the  canal  to  its  fullest  extent, 
to  the  narrower,  which  exposes  the  osseous  portion,  is  gradual, 
and  thus  prevents  the  reflection  of  many  rays  at  this  point. 

The  speculum  for  ordinary  use  should  be  made  of  coin  silver 
or  it  should  be  nickel-plated.  For  the  purpose  of  applying  acids 
or  caustics,  one  of  hard  rubber,  porcelain,  or  glass  is  to  be  pre- 
ferred. The  instrument  is  warmed  by  the  hand  before  being 
used,  and  then  inserted  gently  and  slowly  into  the  meatus  with 
the  right  hand,  the  auricle  being  lifted  up  with  the  left,  and 
the  speculum  held  in  position  by  the  thumb  and  index  finger 
of  the  same  hand.  It  will  thus  be  kept  under  complete  control, 
and  the  examiner  will  be  able  to  turn  it  so  as  to  successively 
view  the  different  parts  of  the  whole  surface  of  the  membrana 
tympani,  and  at  the  same  time  to  thoroughly  straighten  the 
canal  by  pushing  up  its  upper  wall. 

It  is  very  important  that  the  speculum  be  held  properly,  for 
I  have  seen  many  a  student,  for  the  want  of  knowledge  of  this 


1  Treatise  on  Diseases  of  the  Ear.     English  edition,  p.  60. 


METHOD   OF   USING  SPECULUM. 


61 


simple  manipulation,  labor  for  a  long  time  without  getting  any 
view  of  the  membrane,  while  the  instrument  was  resting  on 
some  portion  of  the  projecting  wall  of  the  canal.  A  very  con-, 
siderable  amount  of  pain  may  be  caused  by  the  rude  introduc-- 
tion  of  the  speculum.  I  would  advise  each  practitioner  to  allow 
one  to  be  introduced  into  his  own  auditory  canal,  before  he  be- 
gins to  use  the  instrument  upon  his  patients. 

Having  thus  dilated  the  canal,  the  light  may  be  thrown  into 
it  by  means  of  the  otoscope  or  reflector  of  Troltsch,  which  is  a 
concave  mirror  of  about  three  inches  in  diameter,  having  a  focal 


FIG.  5.— Method  of  Holding  the  Speculum  in  Position. 

distance  of  about  six  inches.  Ordinary  daylight  is  the  best 
source  of  illumination  for  this  mirror,  although  sunlight,  lamp- 
light, gaslight,  electric  light,  that  of  a  candle,  or  the  reflection 
from  a  light-colored  wall,  may  each  be  made  available  in  this 
method  of  examining  the  outer  parts  of  the  ear.  This  is  a  very 
simple  process,  although  many  make  a  difficult  one  of  it.  If  we 
but  use  the  skill  we  acquired  in  our  juvenile  days,  in  throwing 
a  dazzling  light  upon  a  desired  object  by  means  of  a  bit  of 
broken  mirror,  it  will  serve  us  in  good  stead  here.  The  mirror 
is  held  very  lightly  in  the  hand,  and  the  light  is  condensed  upon 
any  desired  part  by  a  very  slight  movement. 


62  METHOD   OF    EXAMINING    MEMBRANA  TYMPANI. 

It  is  now  almost  universally  conceded  by  the  profession  that 
this  method  is  altogether  the  best  that  has  yet  been  suggested 
for  the  examination  of  the  membrana  tympani.  It  was  first 
introduced  to  the  profession  at  large  by  Professor  Anton  Von 
Troltsch,  in  1855,  without  previous  knowledge  that  it  had  been 
suggested  by  others,  although  Dr.  Hoffman,  of  Westphalia,  had 
previously,  in  1841,  used  an  ordinary  shaving  mirror  with  a  cen- 
tral opening  for  the  examination  of  the  ear.  Professor  Edward 
Jaeger,  in  his  work  011  "Cataract  and  Cataract  Operations/' 
published  in  1853,  suggests  that  his  ophthalmoscope  may  be 
used  with  the  concave  mirror  of  four  inches  focal  distance,  for 
the  examination  of  the  external  auditory  canal.  I  have  also 
been  informed  by  numerous  practitioners  that  they  have  often 
used  the  ophthalmoscopic  mirror  for  examining  the  ear  ;  but  in 


FIG.  6. — Method  of  Examining  the  Auditory  Canal  and  Membrana  Tympani.  (A  handle 
to  the  otoscope  other  than  that  formed  by  the  head-band  is  not  necessary.  It  will  be  found 
much  more  convenient  to  make  the  head-band  serve  a  double  purpose.) 

spite  of  all  these  statements  and  the  fact  that  Frank,1  in  his 
work  on  the  ear,  gives  a  sketch  of  Hoffman's  otoscope,  the 
credit  of  the  introduction  into  general  use  of  the  concave  mirror 
for  the  examination  of  the  ear  as  certainly  belongs  to  Troltsch, 
as  the  invention  of  the  ophthalmoscope  to  Heinrich  Helmholtz. 
It  is  somewhat  surprising,  however,  that  after  the  description 
which  Frank  gives  in  his  text-book  of  Hoffman's  method,  and 
the  drawing  which  he  furnishes  of  the  mirror,  no  attention  was 
paid  to  the  subject  until  Troltsch  revived  it  without  knowing 
of  Hoffman's  apparatus. 

I  introduced  the  use  of  the  aural  mirror,  or  otoscope  as  it 
should  be  called,  into  the  practice  of  the  New  York  Eye  and 
Ear  Infirmary,  in  1863,  where  it  soon  superseded  all  other 

1  Practische  Anleitung  zur  Erkentuiss  der  Ohrenlieilkunde,  p.  49. 


TKOLTSCH  S    OTOSCOPE. 


63 


methods,  and  whence  it  has  been  very  generally  adopted  in  the 

United  States. 

It  may  be  safely  said  that  the  adoption  of  this  simple  method 

of  examination  has  done  more  for  the  scientific  and  practical 
study  of  aural  disease  than  any  previous  sugges- 
tion in  this  department.  It  has  placed  within  the 
hands  of  every  practitioner  a  method  by  which  he 
may,  in  a 
few  minutes, 
learn  to  ex- 
a  m  i  n  e  a 
membrane 
which  not  a 
few  physi- 
cians have 
never  seen 
011  the  living 
subject. 

FIG.  ?.— Coiin's        Since  the  use  of  the  electric  light  as  a  means 
of    general    illumination,    excellent   apparatus   are 

constructed  for  examining  the   nose,  pharynx,   and  auditory 

canal. 


FIG.  8. — Author's  Forehead  Band. 


FIG.  8a. — Pomeroy's  Forehead  Mirror. 

I  deem  it  unnecessary,  to  describe   the  numerous  methods 
which  preceded  that  of  Troltsch,  since  they  are  fast  becoming 


64 


BINOCULAR    OTOSCOPY. 


obsolete,  and  their  description  belongs  rather  to  the  history  of 
otology  than  to  a  practical  treatise.  Even  the  method  of  ex- 
amination by  means  of  the  direct  rays  of  the  sun,  which  held 
out  so  long  in  the  hands  of  some  practitioners,  has  at  last  given 
way  to  the  use  of  the  mirror  and  ordinary  daylight. 

It  is  sometimes  convenient  for  the  examiner  and  the  patient  to 
sit  during  the  examination  of  the  membrana  tympani,  and  some- 
times both  may  stand,  or, 
as  I  usually  examine,  the 
patient  may  sit  in  a  re- 
volving chair,  while  the 
surgeon  stands.  The  po- 
sition of  the  patient  will 
not  be  an  important  mat- 
ter, so  long  as  a  good  il- 
lumination is  thrown  into 
the  canal.  A  forehead 
band  is  essential  in  mak- 
ing applications  to  tjie  ear, 
and  it  is  often  convenient 
at  other  times.  I  cannot 
see  any  advantage  in  the 
various  complicated  and 
expensive  bands  with  ball- 
and-socket  joints,  but  I 
use  a  simple  screw  attach- 
ment by  which  the  mirror 
is  fastened  to  the  head-band.  I  prefer  a  head-band  of  elastic 
material,  such  as  india-rubber  webbed  cloth. 

I  never  look  through  the  opening  in  the  mirror,  but  rather 
over  the  rim  of  it.  The  presbyope  and  hypermetrope  will  need 
his  reading  glasses  in  order  to  make  an  examination  of  minute 
points.  A  clip  containing  the  appropriate  convex  lens  may  be 
made  for  those  who  look  through  the  hole  in  the  mirror.  Those 
who  do  not,  will  be  obliged  to  employ  their  glasses  used  for  read- 
ing, in  order  to  get  an  accurate  view  of  some  of  the  details  of  the 
drum-head,  ossicles,  or  the  tympanic  cavity.  A  lens  may  be  in- 
serted in  the  speculum,  as  suggested  by  Dr.  Loring.1 

Mr.  Edward  S.  Ritchie,  of  Boston,  at  the  suggestion  of  Dr. 
Clarence  J.  Blake,2  has  made  an  instrument  which  is  designed  to 
overcome  the  disadvantages  attending  the  exclusion  of  one  eye 
from  the  visual  act  in  operating  upon  the  membrana  tympani : 


FIG.  8b. — Electric  Lamp  for  Illuminating  Ear. 


1  Verbal  Communication,  N.  Y.  Opbihalmological  Society. 
*  Late  Contributions  to  Aural  Surgery.     Boston,  1870. 


OPERATING   OTOSCOPE.  65 

"  It  consists  of  a  hard  rubber  speculum  (Politzer's)  of  the 
largest  size,  fitted  with  a  metallic  rim,  to  which  is  attached  a 
revolving  prism  and  an  arm,  bearing  at  its  outer  end  a  lens  of 
about  an  inch  focus  ;  this  arm  is  movable,  but  sufficiently  firm 
to  remain  fixed  at  any  angle  at  which  it 
is  placed.  The  prism  is  just  within  the 
focal  distance  of  the  lens,  and  its  inci- 
dent face  is  armed  with  a  small  metal 
shield,  having  an  opening  in  the  centre 
corresponding  in  its  short  diameter  to 
the  diameter  of  the  pencil  of  light  falling 
upon  it  from  the  lens. 

"The  advantage  of  a  prism  over  a 
mirror  or  other  reflecting  surface  is, 
that  we  have  almost  total  reflection ; 
and  but  little  of  the  light  concentrated 
upon  the  prism  by  the  lens  is  lost. 

"In    operating,   an   assistant    is  re-  s'cope!*1 

quired  to  draw  the  auricle  upward  and 

backward,  and  keep  the  speculum  in  position,  with  the  pencil 
of  light  upon  the  opening  in  the  shield  of  the  prism.  It  is  not 
claimed  for  this  instrument  that  it  at  all  supersedes  the  head 
mirror  of  Troltsch,  but  it  is  certainly  of  great  advantage  in  the 
more  complicated  operations,  where  a  steady  and  uniform  illu- 
mination is  indispensable.  The  instrument,  as  a  whole,  weighs 
only  about  one  hundred  and  fifty  grains,  and  can  be  made  much 
lighter  ;  so  that  when  once  firmly  inserted  in  the  meatus,  it  re- 
mains in  position,  and  there  is  no  necessity  for  holding  it  nor 
fear  of  its  slipping  out  of  place  during  the  operation." 

The  practitioner  will  often  be  obliged  to  examine  the  ear  and 
pharynx  of  a  patient  who  is  too  ill  to  get  up  from  the  bed.  The 
light  from  a  candle  or  of  Colin's  lamp  then  becomes  a  very  con- 
venient and  ample  means  of  illumination.  The  finest  changes 
on  a  membrana  tympani  and  in  the  auditory  canal  may  be  ob- 
served by  the  aid  of  the  otoscope  and  such  a  light. 

« 

EXAMINATION  OF  THE  PHARYNX  AND  EUSTACHIAN  TUBES. 

After  having  heard  the  patient's  history,  and  having  ascer- 
tained the  amount  of  hearing,  we  may  proceed  to  the  examina- 
tion of  the  pharynx  and  nares,  and  mouths  of  the  Eustachian 
tubes.  Although  the  profession  has  been  a  long  time  in  coming 
to  an  appreciation  of  the  fact,  it  is  now  generally  conceded  that 
the  starting-point  of  a  large  percentage  of  aural  cases  is  in  these 
parts. 

5 


66 


PHAKYXX  AND   EUSTACHIAN   TUBES. 


The  pharynx  is  best  examined  by  turning  the  patient's  face 
to  an  open  window,  and  holding  the  tongue  by  means  of  Turck's, 

or  a  simple  hinge  speculum.  Turck's 
instrument  is  to  be  preferred  to  others, 
because  the  hand  of  the  examiner  does 
not  obscure  the  view  in  its  use.  I 
often,  however,  use  a  reflector  and  ordi- 
nary daylight  for  an  inspection  of  the 
pharynx,  and  it  has  some  advantages 
over  a  direct  illumination. 
•  FIG.  10.— Hinge  Speculum.  Some  surgeons  prefer  to  use  artificial 

light  in  examining  the  pharynx  as  well  as  other  parts  of  the 
body,  but  I  much  prefer  ordinary  daylight  for  all  examinations, 
when  it  is  possible  to  use  it,  to  that  from  any  artificial  source, 
or  to  the  direct  rays  of  the  sun,  since  it  seems  to  me  that  the 
natural  hues  are  thus  best  observed.  In  the  evening,  of  course, 


Q 


Pro.  11.— Turck's  Speculum. 

artificial  light  must  be  used.  A  reflector  should  then  be  em- 
ployed. It  is  well  to  have  the  reflector  attached  to  a  forehead 
band,  as  in  the  practice  of  rhinoscopy  or  pharyngoscopy,  which 
will  bS  immediately  described  ;  but  I  may  defer  any  description 
of  what  to  observe  on  examining  the  fauces  and  pharynx  until 
we  come  to  speak  of  pharyngeal  disease. 


RHIXOSCOPY. 


Rhinoscopy,  as  a  practical  method  of  examining  the  posterior 
nares,  was  suggested  by  Sir  William  Wilde  in  his  treatise  on 
"Aural  Surgery,"  having  previously  been  spoken  of  by  Bozzini, 


EHINOSCOPY.  67 

as  a  possible  method  of  examining  the  parts  behind  the  hanging 
palate,  in  a  book  published  in  Weimar  in  1807. l 

Professor  Czermak,  of  Prague,  following  up  Turck's  investi- 
gations on  the  larynx,  was  the  first  to  actually  introduce  rhino- 
scopy  into  anything  like  general  use  ;  while  Dr.  Semeleder, 
Surgeon  to  the  Gumpendorf  Hospital  in  Vienna,  and  afterward 
Surgeon  to  the  Archduke  Maximilian,  while  in  Mexico,  gave  us 
the  first  full  account  of  what  was  to  be  observed  by  this  means, 
with  some  interesting  cases.  Voltolini,  of  Breslau,  has  also 
added  much  to  our  knowledge  of  the  value  of  this  means  of 
diagnosis. 

It  is  by  no  means  necessary  that  every  aural  patient  should 
be  examined  with  the  rhinoscope,  nor  will  the  most  accom- 
plished manipulator  be  able  to  see  the  mouth  of  the  Eustachian 
tubes  in  every  case  ;  but  every  one  who  attempts  to  treat  the 
disease  of  the  organ  of  hearing  will  find  his  diagnosis  very  often 
facilitated  by  an  inspection  of  these  parts ;  for  example,  when 
any  unusual  difficulty  is  experienced  in  entering  the  mouth  of 
the  Eustachian  tube. 

For  the  practice  of  rhinoscopy  we  need  a  lamp,  or  other 
source  of  artificial  illumination,  a  small  mirror,  a  tongue  spat- 
ula, and  a  concave  mirror  that  may  be  attached  to  a  forehead 
band  or  placed  on  Semeleder's  spectacle  frame.  Any  brightly 
burning  lamp,  or  a  good  Argand  gas-burner,  will  answer  as  a 
source  of  illumination. 

Various  kinds  of  costly  apparatus  for  the  purpose  of  con- 
densing the  light  have  been  suggested  and  employed.  If  the 
surgeon  be  not  satisfied  with  an  ordinary  lamp,  perhaps  the  ap- 
paratus of  Tobold  will  be  found  the  best.  In  some  instances, 
although  not  always,  an  instrument  for  holding  back  the  uvula 
is  required.  Various  appliances  have  been  suggested  for  this 
purpose — nooses,  hooks,  spatulas,  and  so  on — for  any  of  which 
a  surgeon  of  ordinary  tact  will  find  a  substitute  when  wanted,, 

It  is  above  all  things  requisite,  that  the  patient  should  be 
tractable,  and  this  tractability  is  perhaps  more  common  than 
many  surgeons  imagine.  Those  who  precede  all  their  manipu- 
lations by  an  appeal  to  their  patients  to  be  very  quiet,  to  be  sure 
not  to  stir,  not  to  mind  a  little  pain,  etc.,  and  who  at  the  same 
time  make  a  great  show  of  instruments,  will  generally  have  in- 
tractable and  timid  patients ;  but  he  who  goes  quietly  to  work, 
will  find  few  patients  that  will  not  submit  with  more  or  less 
patience  to  all. such  manipulations  as  are  required  in  rhinoscopy, 
the  use  of  the  Eustachian  catheter,  and  the  like. 

1  Laryngoscopy  and  Khinoscopy.  By  F.  Semeleder.  Translated  by  Dr.  E.  T.  Cas- 
well,  1866. 


68  RHINOSCOPY. 

The  patient  being  seated  in  front  of  the  examiner,  with  a 
good  light  at  one  side,  the  mouth  is  well  opened,  and  the  tongue 
held  by  means  of  the  depressor  mentioned  above.  The  surgeon 
should  be  careful  in  placing  the  tongue-depressor,  so  that  he 
may  not  cause  undue  pressure,  which  will  produce  gagging,  and 
prevent  all  further  manipulations.  The  light  is  then  turned 
upon  the  pharynx  by  the  head  mirror,  so  that  it  is  accurately 
focused,  when  the  parts  will  be  illuminated. 

Having  secured  a  good  view  of  the  pharynx,  uvula,  and  ton- 
sils, the  throat  mirror  is  to  be  introduced.  This  instrument  is  first 
warmed  by  holding  it  for  an  instant  over  the  flame  of  the  lamp  ; 
its  heat  is  then  tested  by  placing  it  on  the  back  of  the  hand,  after 
which  it  is  gently  and  quickly  introduced,  with  its  reflecting  face 


FIG.  12. — Anterior  Nares  Speculum.  FIG.  13. — Goodwillie's  Nasal  Speculum. 

upward,  into  the  space  between  the  soft  palate  and  cavity  of  the 
posterior  pharyngeal  wall.  There  are  some  patients,  however, 
in  whom  it  will  be  impossible  to  make  a  rhinoscopic  examina- 
tion, on  account  of  the  small  space  between  the  uvula  and  pos- 
terior wall  of  the  pharynx.  A  very  few,  also,  have  such  irritable 
throats  as  also  to  render  such  an  examination  impracticable. 

The  examination  of  the  nostrils  anteriorly — anterior  rhino- 
scopy,  as  it  is  called  by  Cohen ' — is  often  an  important  part  of 
the  examination  of  a  case  of  aural  disease. 

It  is  very  often  sufficient  to  place  the  patient  in  front  of  a 
good  light,  and  open  the  nares  by  pressing  upon  the  tip  of  the 
nose.  A  thorough  examination  of  the  anterior  nares  may  be 
made  with  any  of  the  specula  of  which  cuts  are  here  given. 

Zaufal,  of  Prague,  has  of  late  years  laid  great  stress  upon 
anterior  rhinoscopy.  He  has  devised  a  set  of  nasal  specula  for 
this  method  of  examination,  and  he  has  contributed  largely  to 
our  knowledge  of  the  morbid  appearances  of  the  nasal  cavities. 
A  little  experience  must  be  had  with  these  specula,  before  the 
surgeon  will  be  willing  to  trust  himself  to  deductions  from  what 
he  may  see. 

1  Diseases  of  the  Throat,  p.  75. 


ZAUFAL'S  SPECULA.  69 

ZaufaFs  specula  are  long  tubes  of  various  sizes  adapted  to 
the  inferior  meatus  of  the  nose,  with  a  funnel-like  extremity 
through  which  the  light 
is  thrown.      When    Dr. 
Weir,  of  this  city,  was 
an  aural  surgeon  to  one 
of    our    infirmaries,    he 
used  the  tube  of  the  en- 
doscope    for    the    same 

/•      -i  j.    •     •  FIG.  13a. — Elsberg's  Nasal  Speculum. 

purpose  of  obtaining  an 
anterior  view  of  the  mouth  of  the  Eustachian  tubes,  but  Zaufal 
has  made  much  greater  publicity  of  the  results  of  his  examina- 
tions by  this  method — and  probably  never  knew  of  Weir's  work 
in  the  same  direction. 


EXAMINATION  OF  THE  EUSTACHIAN  TUBE. 

We  may  now  turn,  as  the  next  step  in  our  examination  of  a 
case  of  supposed  aural  disease,  to  the  investigation  of  the  con- 
dition of  the  Eustachian  tube  and  cavity  of  the  tympanum. 
The  means  of  this  examination  may  be  classified  as  follows  : 
I.  The  Eustachian  catheter. 
II.  Politzer's  method. 

III.  Valsalva's  method. 

IV.  Eustachian  bougies. 

From  the  date  of  the  promulgation  of  the  use  of  the  Eus- 
tachian catheter  by  the  postmaster  of  Versailles,  Guyot,  until 
Toynbee's  time,  the  views  of  the  profession  as  regards  the  use 
of  this  instrument  have  varied  exceedingly.  At  one  time  it  was 
almost  utterly  rejected  by  the  greater  number  of  respectable 
practitioners,  and  at  another  time  has  been  considered  by  them 
as  a  panacea  in  the  treatment  of  aural  disease.  The  text-books 
of  Wilde  and  Toynbee,  which  attached  very  little  importance  to 
the  use  of  the  Eustachian  catheter,  and  Avhich  bear  intrinsic 
evidence  that  the  authors  did  not  choose  to  be  very  familiar 
with  the  details  of  the  proper  employment  of  the  instrument, 
probably  did  more  than  anything  else  to  cause  the  profession  in 
our  own  country  to  settle  down,  until  a  few  years  since,  into  the 
belief  that  the  Eustachian  catheter  was  always  a  useless  and 
sometimes  a  dangerous  instrument.  I  well  remember  the  dis- 
couraging response  of  a  prominent  American  practitioner,  who 
had  then  had  large  experience  in  aural  disease,  to  my  state- 
ment, at  the  beginning  of  my  active  professional  life,  that  I  pro- 
posed to  use  the  Eustachian  catheter  in  the  treatment  of  diseases 


70 


EUSTACHIAN  CATHETER. 


of  the  ear,  that  he  was  glad  to  say  that  he  never  had  used  the 
instrument,  and  this  was  the  common  sentiment  among  our  re- 
spectable practitioners  until  the  publication  of  an  English  trans- 
lation of  Troltsch's  work  on  the  ear.     In  respect 
tf      f     to  the  change  in  sentiment  in  this  regard,  I  only 
ff       //       need  to  say,  that  nearly  every  American  surgeon 
I!        /y  who  now  treats  aural  disease,   attaches  much 

•  importance  to  the  use  of  this  instrument. 

We  have  now  to  speak  of  the  Eustachian 
catheter  as  a  means  of  diagnosis.  The  material 
of  which  the  instrument  should  be  made  may  be 
either  hard  rubber  or  alloyed  silver.  For  the 
injection  of  warm  vapors  the  hard  rubber  in- 
strument is  the  only  one  to  be  used,  because  the 
heat  will  very  soon  nlake  it  impossible  for  a  pa- 
tient to  bear  the  metal  instrument  in  the  nostril. 
For  myself,  I  use  the  hard  rubber  instrument  for 
all  purposes. 

In  the  method  of  introduction,  we  proceed  as 
did  Archibald  Cleland,  an  English  surgeon,  who, 
after  Guyot,  did  the  most  to  demonstrate  the 
utility  of  entering  the  mouth  of  the  Eustachian 
tube  with  an  instrument,  and  we  pass  the  cathe- 
ter through  the  nostril.  It  is  very  difficult  to 
imagine  how  the  Versailles  layman  succeeded  in 
introducing  an  instrument  into  the  tube,  through 
the  mouth.  He  certainly  did  not  use  a  catheter 
such  as  we  now  employ,  and  which  is  represented 
on  this  page.  This  instrument  is  a  delicate 
tube  of  about  six  inches  in  length,  with  a  slight 
curve  at  its  extremity.  A  long  and  flexible 
catheter  might,  it  is  true,  be  passed  behind  the 
soft  palate  into  or  opposite  the  mouth  of  the 
tube,  and  this  is  the  operation  which  Guyot 
demonstrated  to  the  Paris  Academicians,  and 
which,  by  removing  mucus  from  about  the  trum- 
pet-shaped pharyngeal  extremity  of  the  canal, 
relieved  his  impairment  of  hearing.1 

The  various  steps  in  the  operation  of  intro- 
ducing the  Eustachian  catheter  are  as  follows  : 

] .  Let  the  patient  be  seated  on  a  chair,  with 
a  little  higher  back  than  usual,  so  that  the  head  may  be  sup- 
ported. If  the  patient  be  a  child  or  a  very  timid  subject,  it  may 


FIG.  14.  —  Eusta- 
chian Catheters  (ac- 
tual size). 


For  a  fuller  account  of  Guyot's  operation,  see  Introductory  Chapter. 


EUSTACHIAN   CATHETER.  71 

rest  its  head  against  a  table  or  wall,  or  what  is  better,  be  sup- 
ported by  an  adult. 

I  seldom  use  the  Eustachian  catheter  in  young  children  ;  for  them  I  almost 
exclusively  use  Politzer's  method  of  inflating  the  middle  ear. 

2.  Let  the  patient  blow  his  nose,  so  as  to  moisten  the  passage 
and  remove  any  collections  of  mucus,  while  the  surgeon  takes 
the  catheter,  thoroughly  cleansed  and  warmed,  and  forces  air 
through  it  in  order  to  be  sure  that  it  is  permeable. 

3.  The  operator,  standing  a  little  to  on6  side,  draws  down  the 
upper  lip  with  the  left  hand,  and  with  the  thumb  and  finger  of 


FIG.  15. — Introduction  of  Eustachian  Catheter. 

his  right  hand  lightly  holds  the  catheter  close  to  the  funnel- 
shaped  end,  nearly  in  a  vertical  position,  so  that  the  guide  or 
projection  at  the  side  of  the  funnel-shaped  extremity  looks 
directly  downward,  until  the  catheter  has  entered  the  meatus, 
when  it  is  quickly  turned  to  an  approach  to  the  horizontal 
position,  when  the  beak  will  rest  on  the  floor  of  the  nasal 
meatus,  close  to  the  septum,  with  its  convexity  upward. 

4.  The  catheter  is  then  to  be  slid  or  insinuated  backward  with 
a  gentle  motion,  keeping  it  as  close  as  possible  to  the  floor  of  the 
meatus,  gradually  elevating  the  handle  until  the  instrument  be- 
comes perfectly  horizontal  and  the  beak  rests  upon  the  posterior 
wall  of  the  pharynx. 


72  EUSTACHIAN   CATHETER. 

5.  At  this  point  the  funnel-shaped  end  of  the  catheter  in  the 
hand  of  the  operator  is  to  be  raised  a  little  above  the  horizontal 
line  and  at  the  same  time  withdrawn  a  little. 

6.  Turn  the  catheter  about  a  quarter  on  its  axis,  from  within 
outward.     This  motion  lifts  the  beak  of  the  instrument  into  the 
mouth  of  the  Eustachian  tube.    This  latter  movement  is  aided 
somewhat  by  the  contraction  of  the  soft  palate,  which  performs 
a  swallowing  movement,  raises  itself,  and  lifts  the  beak  of  the 
instrument  into  the  tube.     Once  in  position  the  catheter  should 


FIG.  16. — The  Eustachian  Catheter  in  Position. 

not  cause  the  patient  any  inconvenience  in  speaking  or  swal- 
lowing, and  the  guide  will  lie  at  about  an  angle  of  twenty-five 
degrees  with  the  tragus. 

The  difficulties  that  are  found  in  introducing  the  catheter, 
simple  manipulation  as  it  is,  arise  from  two  causes  : 

First,  the  surgeon  does  not  always  hold  the  instrument  in  a 
vertical  position  (see  Fig.  15)  until  he  has  got  the  beak  well  in 
the  meatus.  A  failure  to  do  this  will  often  cause  the  instrument 
to  pass  between  the  inferior  and  middle  turbinated  bones,  in- 
stead of  along  the  floor  of  the  meatus,  which  must  be  hugged  in 
order  that  the  instrument  may  get  to  the  mouth  of  the  tube. 

Second,  the  patient  is  apt  to  shut  his  eyes  spasmodically  and 
contract  his  facial  muscles,  and  thus  prevent  the  relaxation  of 
the  parts  that  is  necessary  during  the  manipulation.  This  diffi- 
culty is  only  to  be  overcome  by  persuading  the  patient  to  open 
his  eyes  and  look  about  the  room,  which  can  be  done  if  the  sur- 


DIAGNOSTIC   TUBE. 


73 


geon  have  a  quiet,  assuring  manner.  This  difficulty  usually 
passes  away  with  the  second  or  third  use  of  the  instrument,  and 
sometimes  it  does  not  arise. 

Having  introduced  the  catheter  we  may  force  air  through  it 
into  the  cavity  of  the  tympanum,  by  means  of  an  air-bag  whose 
nozzle  should  fit  accurately  in  the  funnel-shaped 
extremity  of  the  nasal  instrument.  Air  may  also 
be  blown  in  from  the  lungs  of  the  examiner  through 
a  slender  bit  of  rubber  tubing,  the  tips  of  which  are 
placed  in  the  opening  of  the  catheter  and  the  mouth 
of  the  examiner  respectively.  The  use  of  the  rub- 
ber-bag or  syringe  is  to  be  preferred  to  the  latter 
method,  on  the  ground  that  it  is  not  likely  to  offend 
the  natural  feelings  of  the  patient,  against  the  in- 
troduction of  air  from  the  lungs  of  the  examiner. 

After  air  has  been  forced  into  the  middle  ear  in 
this  manner,  the  membrana  tympani  should  again 
be  examined  by  the  surgeon,  to  determine  if  it  has 
become  injected,  or  if  it  has  undergone  any  change 
in  position  ;  that  is  to  say,  he  should  see  whether  the  current 
has  actually  reached  the  cavity  of  the  tympanum  or  not. 

I  have  caused  an  exact  representation  to  be  made  of  the  size 
and  curve  of  the  Eustachian  catheters  used  by  me,  for  I  was  for 


FlG.  18.— Diagnostic  Tube. 

a  long  time  greatly  annoyed  by  the  difficulty  which  I  often 
found  in  introducing  instruments  of  a  larger  calibre  and  curve. 
I  am  constrained  to  believe  that  the  catheter  would  be  much 
more  widely  employed,  were  instruments  of  small  calibre  and 
curve  generally  figured  in  the  text-books  and  sold  in  the  shops. 

Most  authorities  recommend  the  use  of  an  instrument  like 
.the  stethoscope,  which  is  placed  in  the  ear  of  the  patient  while 


74  POLITZEE'S  METHOD  OF  INFLATION-. 

the  air  is  being  driven  through  the  tube,  and  they  claim  to  be 
generally  able  to  decide  as  to  whether  the  air  enters,  by  the 
sound  communicated  through  the  tube.  I  believe  it  will  be 
found  very  difficult  to  distinguish  sounds  proceeding  from 
the  pharyngeal  mouth  of  the  tube  from  those  produced  in  the 
cavity  of  the  tympanum,  and  I  do  not,  therefore,  attach  that 
importance  to  the  use  of  the  stethoscope  in  this  manner,  that 
has  been  usually  ascribed  to  it ;  but  I  rely  more  upon  the  ap- 
pearances of  the  membrane  of  the  tympanum  after  the  air  has 
been  forced  in,  with  some  attention  also  to  the  sensations  of 
the  patient,  as  to  where  the  air  is  felt,  than  upon  the  use  of  the 
diagnostic  tube. 

I  very  rarely  make  use  of  the  instrument.  It  was  formerly 
called  the  otoscope,  a  manifestly  improper  name,  as  Kramer 
said.  The  mirror  for  examining  the  canal  and  membrana  tym- 
pani  is  the  only  otoscope. 

POLITZER'S  METHOD  OF  INFLATING  THE  EAR. 

The  next  means  of  examining  the  condition  of  the  Eusta- 
chian  tube  and  cavity  of  the  tympanum  is  named,  from  the 
physician  who  suggested  it,  Politzer's  method.  It  is  a  means  of 
diagnosis  and  treatment  of  very  great  value,  and  we  owe  very 
much  to  Professor  Adam  Politzer,  of  Vienna,  for  this  method  of 
sending  air  into  the  middle  ear. 

As  is  very  well  known,  in  the  action  of  swallowing,  the 
uvula  rests  upon  the  pharyngeal  wall  so  as  to  shut  off  the  upper 
from  the  lower  pharyngeal  space  ;  so  that  persons  affected  with 
cleft  palate,  who  cannot  thus  separate  these  spaces,  are  greatly 
inconvenienced  by  the  passage  of  solids  and  fluids  upward  to 
the  posterior  nares.  It  was  long  ago  shown  by  Toynbee,  that  the 
pharyngeal  orifice  of  the  Eustachian  tube  opened  during  the 
swallowing  process.  Politzer's  method  takes  advantage  of  these 
physiological  facts  in  the  following  way :  the  person  to  be  ex- 
amined takes  a  little  water  in  the  mouth,  while  the  surgeon 
places  the  nozzle  of  an  air-bag  into  one  of  the/  nostrils,  closes  the 
other  with  his  finger,  and  causes  the  patient  to  swallow  the 
water  at  a  given  signal  previously  agreed  upon,  when  he  forces 
in  the  air  by  compressing  the  india-rubber  bag.  I  usually  say 
"  now  ;  "  upon  which  the  patient  swallows. 

In  examining  children,  I  use,  as  suggested  by  Mr.  Hinton, 
a  piece  of  rubber  tubing,  and  force  the  air  from  my  own  lungs, 
on  giving  a  signal  by  raising  the  hand. 

The  effect  of  the  air  thus  forced  in  upon  the  membrana  tym- 
pani  is  often  wonderful.  A  person  who  has  become  deaf  to 


POLITZEE'S  METHOD. 


75 


ordinary  conversation,  sometimes  in  an  instant  again  hears 
the  familiar  tones  of  human  conversation,  and  feels  himself  in 
a  new  world.  In  such  a  case,  mucus  has  obstructed  the  calibre 
of  the  tube,  or  the  mobility  of  the  ossicles  has  been  interfered 
with.  In  the  former  case  it  is  driven  away  by  the  current  of 
air,  which  must  of  necessity  go  against  the  mouths  of  the  tube, 
and  will  usually  pass  on  into  the  middle  ear.  The  patient's  own 
testimony  will  usually,  although  not  always,  be  conclusive  as 
to  whether  the  air  entered  the  ear.  The  exceptional  cases  are 
those  in  which  the  Eustachian  tube  and  the  cavity  of  the  tym- 
panum have  become  so  nar- 
rowed by  a  hypertrophy  and 
sclerosis  of  the  lining  mucous 
membrane  that  only  a  very 
narrow,  feeble  current  can  en- 
ter, or  perhaps  where  atrophy 
of  tissue  has  rendered  it  less 
sensitive  than  normal.  We 
shall  have  need  to  dwell  upon 
the  uses  of  Politzer's  method 
when  we  are  discussing  the  af- 
fections of  the  middle  ear,  and 
I  therefore  content  myself  with 
this  description  of  it,  while  we 
pass  on  to  Valsalva's  method  of 
inflating  the  ear. 

A  great  many  modifications 
of  Politzer's  methods  of  proced- 
ure, chiefly,  however,  as  regards 
swallowing  as  a  signal  for  the 
operator  to  compress  the  air- 
bag,  have  been  made  by  various 
persons.  Some  of  these  bear 


r's  APPa- 

iodine  or  other 


FlG  m_Method  of  Using 

ratus  (with  box  for  containin 

evidence  of  the  tendency  of  the  evaporating  substance). 
human  mind  to  seek  change,  if  only  for  the  sake  of  change. 
Gruber  causes  his  patients  to  say  hie,  hoc,  instead  of  swallow- 
ing upon  the  signal.  He  enters  into  a  laborious  argument 
to  prove  that  his  method  is  better  than  that  of  swallowing.  One 
of  his  objections  to  Politzer's  method  is,  that  patients  object 
to  drinking  from  the  glasses  which  he  has  near  at  hand.  Dr. 
J.  Oscroft  Tansley,1  of  New  York,  proposed  that  patients,  instead 
of  swallowing,  shall  blow  as  if  about  to  blow  out  a  lighted 
candle.  Both  of  these  modifications  of  one  minor  part  of  Polit- 


1  Medical  Record,  March  1C,  1878. 


76  TANSLEY'S  MODIFICATION. 

zer's  great  invention,  especially  Tansley's,  are  of  value  in  cer- 
tain cases.  They  are  not  more  important  as  modifications  of  the 
method,  than  Hinton's  use,  in  the  case  of  children,  of  an  india- 
rubber  tube,  through  which  air  is  forced  from  the  lungs  instead 
of  from  an  air-bag.  The  late  Dr.  Peter  Allen '  substituted  a  nasal 
pad,  which  is  pressed  against  the  opening  into  the  nostrils,  in- 
stead of  into  one  of  them.  Two  air-pads  are  mounted  on  a  piece 
of  covered  copper  wire.  These  can  be  brought  close  together 
or  separated  so  as  to  stop  up  the  openings  into  the  nostrils. 

The  pads  are  held  in  place  by  the  metal  which  serves  as  a 
handle.  There  is  a  hole  through  each  pad,  and  these  holes  com- 
municate with  two  short  bits  of  rubber  tubing  joining  into  a 
single  tube.  The  pipe  of  the  air-bag  used  for  inflating  is  inserted 
in  this  latter,  and  the  apparatus  appears  as  in  the  engraving. 

This  instrument  contains  a  very  useful  modification  of  Po- 
litzers  apparatus,  and  it  is  much  preferred  to  the  original  by 


PIG.  20. — Dr.  Allen's  Nose  Pads  for  Politzer's  Apparatus. 

some  surgeons.  There  is  no  advantage  in  the  double  bag  such 
as  is  employed  in  the  nebulizers,  and  which  has  also  been  pro- 
posed for  Politzer's  method. 

Tansley's  method  of  blowing  instead  of  swallowing  was  sug- 
gested to  him,  as  he  states,  after  practising  Holt's  method.  Dr. 
E.  E.  Holt  found  that  the  air  readily  entered  the  tympana  by 
closing  the  lips  tightly  and  distending  the  mouth  and  cheeks 
easily  with  air,  and  then  discharging  the  air-bag  as  in  Politzer's 
method.  He  consequently  caused  the  patients  to  undertake 
this  manoeuvre  instead  of  swallowing.  I  find  the  methods  of 
Gruber  and  Tansley  very  useful  in  many  cases,  but  in  by  far 
the  most  instances,  I  prefer  to  cause  my  patients  to  swallow  on 
a  given  signal. 

I  am  told  on  reliable  authority,  that  in  one  of  the  continental 
cities,  rival  teachers  of  otology  lay  great  stress  upon  the  impor- 

1  Treatise  on  the  Ear,  p.  97. 


VALSALVA'S  METHOD.  77 

tant  point  as  to  whether  the  air-bag  is  pressed  upon  on  its  side 
or  its  distal  end,  when  used  for  inflation.  One  teacher  causes  his 
pupils  always  to  compress  the  bag  on  one  side,  while  the  other 
as  strenuously  insists  that  it  can  only  be  properly  employed  by 
compressing  it  from  the  distal  end. 

VALSALVA'S  METHOD. 

The  distinguished  anatomist  Valsalva,  who  is  well  known  to 
the  profession  by  his  treatise  on  the  ear,  suggested  a  means  of 
inflating  the  membrana  tympani,  which  has  become  so  popular 
as  to  be  used  by  nearly  two-thirds  of  all  the  patients  who  come 
to  physicians  on  account  of  their  ears.  It  has  been  recom- 
mended by  generations  of  medical  men  as  a  means  of  curing 
affections  of  the  ear,  or  of  determining  if  the  Eustachian  tube 
be  open,  or  the  drum-head  broken.  Universal  as  is  its  use,  I  re- 
gard it  as  almost  a  useless  and  not  an  entirely  safe  method.  It 
consists  essentially  in  forcing  air  into  the  ear,  after  a  vigorous 
inspiration,  the  mouth  and  nostrils  being  closed,  It  will  be  ob- 
served that  when  the  ear  is  inflated  by  this  method,  a  very  great 
use  of  the  muscles  of  the  chest  is  made  ;  and  just  in  this  lies  the 
danger  to  the  ear.  This  vigorous  expansion  of  the  chest  causes 
a  congestion  of  the  ear  which  is  sometimes  more  or  less  perma- 
nent, and  materially  harms  the  part  by  increasing  the  flow  of 
blood  to  it.  There  is  another  objection  to  the  frequent  employ- 
ment of  the  Valsalvian  method,  or  experiment,  as  it  is  some- 
times styled.  It  soon  ceases  to  have  its  momentary  effect  of 
increasing  the  hearing  distance,  which  it  does  by  rendering  the 
membrane  of  the  drum  tenser,  and  then  the  membrane  becomes 
relaxed  and  flaccid,  so  that  I  have  sometimes  seen  the  mem- 
brana tympani  of  patients  who  have  been  in  the  daily  and  per- 
haps hourly  habit  of  forcing  air  into  the  ears,  flap  to  and  fro 
like  a  valve,  on  the  slightest  movements  of  the  nostrils. 

This  latter  objection,  of  course,  applies  to  Politzers  method 
if  it  be  very  frequently  practised  ;  but  as  it  must  be  done  by 
means  of  an  apparatus,  patients  are  not  so  apt  to  take  it  into 
their  own  hands.  I  do  not  now  advise  the  use  of  the  Valsalvian 
method  in  the  treatment  of  aural  disease,  and  as  a  means  of 
diagnosis  it  is,  in  most  cases,  vastly  inferior  to  the  use  of  the 
catheter  or  Politzer's  method. 

BOUGIES. 

I  may  add  a  word  about  the  last-named  means  of  examining 
the  Eustachian  tube,  namely,  bougies.  Filiform  catgut  bougies 
may  sometimes  be  employed  with  advantage  in  determining  if 


78  BOUGIES. 

the  non-entrance  of  air  by  the  catheter  or  Politzer's  method,  be 
due  to  a  stricture ;  but  the  need  for  their  employment  occurs 
only  in  a  very  limited  number  of  cases,  and  when  they  are  used 
great  care  and  judgment  are  necessary.  This  subject  will  be 
fully  discussed  in  the  chapter  on  "  Chronic  Xon-suppurative  In- 
flammation of  the  Middle  Ear."  The  examination  of  the  condi- 
tion of  the  drum-head  and  ossicles  by  Siegle's  otoscope  will  also 
be  discussed  in  the  same  place. 

It  will  be  understood  by  the  reader  that  very  many  cases  of 
aural  disease — for  example,  those  of  the  external  auditory  canal 
— will  not  require  the  exhaustive  examination  that  has  just  been 
detailed,  yet  many  cases  will  require  a  systematic  and  complete 
observation,  such  as  I  have  attempted  to  delineate,  in  order  that 
an  exact  and  consequently  valuable  diagnosis  may  be  made. 
The  time  thus  consumed  is  sometimes  considerable,  but  it  is  not 
as  great  as  those  who  simply  read  these  descriptions  will  per- 
haps imagine.  The  details  occupy  more  in  description  than  in 
execution  ;  and  their  strict  performance  will  of  themselves  in 
time  make  those  who  carry  them  out,  good  observers  of  the 
phenomena  of  disease. 


THE   EXTERNAL    EAR. 


CHAPTER  III. 


ANATOMY  OF  THE  AUEICLE  AND  THE  EXTEBNAL  AUDITOBY 

CANAL. 

Auricle.  —  Etymology.  —  Anatomy  of  Muscles,  Intrinsic  and  External.  —  Physiology.  — 
Blood-vessels.  —  Nerves.  —  External  Auditory  Canal.  —  Anatomy  of  Curvature.  — 
Ceruminous  Glands.  —  Hairs  in  CanaL  —  Auditory  Canal  of  Dog  and  Cat.  —  Relations 
of  Canal  to  Parotid  Gland,  Inferior  Maxilla,  Mastoid  Process,  and  Dura  Mater.  — 
Blood-vessels  and  Nerves. 

THE  auricle  (auricula,  external  ear)  is  perhaps  little  more  than 

an  appendage  to  the  human  organ  of  hearing,  although  it  is 

such  an  important  part  of  the  ear  of  certain  animals.    Its  gen- 

eral shape  is  that  of  a  funnel.    Its  frame-work,  or  basis,  is  made 

up  of  flexible  flbro-cartilage,  and  it  is 

from  one  to  two  millimetres  in  thick- 

ness.    The  cartilage  is  of  the  variety 

known  as  reticular,  and  it  is  covered  by 

perichondrium  which    contains    many 

elastic  fibres.   These  fibres  pass  into  the 

substance  of  the  cartilage,  and  form  a 

network  in  the  meshes  of  which  small 

cartilage  cells  are  embedded.     From  the 

time  of  Rufus  of  Ephesus  the  different 

parts  of  the  auricle,  which  give  it  its 

beautiful  and  useful  shape,  have  been 

named  as  follows  : 

The  edge  that  forms  the  outer  border 
of  the  auricle  is  called  the  helix,  from 
a  Greek  word,  eXif,  anything  twisted, 
cAio-o-o),  to  turn  around.  This  ridge  varies 
in  breadth,  and  is  more  or  less  distinct 

in    different     individuals,    according    to 

the  care  that  has  been  taken  to  preserve 
the  shape  of  the  ear.     It  begins  at  a 

point  on  the  concave  surface  of  the  cartilage,  called  the  spine  or 
crest  of  the  helix,  spina  seu  crista  helicis.     By  following  down 
the  posterior  border  with  the  finger,  it  will  be  seen  that  its  tissue 
6 


FIG.  21.—  The  Auricle,   i,  He- 

Kx  ;  2,  anti-helix;  8,  Iowa  hdicia; 

"  " 


82 


ANATOMY    OF   THE   AURICLE. 


does  not  pass  into  the  lobe  of  the  ear,  but  that  the  latter  is 
formed  by  the  integument  alone. 

Just  beneath  the  helix  is  a  fossa — fossa  navicularis,  or  boat- 
like  fossa — separating  it  from  a  second  ridge-like  border,  the 
anti-helix.  Just  in  front  of  the  opening  into  the  auditory  canal 
the  cartilage  becomes  thickened,  and  forms  a  projection  or  edge 
called  the  tragus  (Latin  for  goat),  because  hairs  usually  grow 
upon  this  part,  which  were  supposed  by  the  ancients  to  give  it  a 
certain  kind  of  resemblance  to  the  beard  of  that  animal.  Just 


F.c. 


FIG.  22. — Profile  View  of  the  Skull,  with  the  Skeleton  or  Cartilage  of  the  Auricle,  as  well 
as  that  of  the  External  Auditory  Canal.  The  latter  is  exposed  and  drawn  downward,  c.m. 
(after  Henle).  1,  Meatus  auditorius  externus ;  2,  tuberculum  articulare  of  the  temporal 
bone ;  3,  mastoid  process ;  t,  transverse  section  of  the  zygomatic  process ;  H,  helix  ;  A. A., 
anti- helix ;  F.t.,  fossa  triangularis  ;  S,  scapha,  or  fossa  navicularis;  F.C.,  concha;  C.  h., 
cauda  helicis ;  A.t.,  anti-tragus  ;  T,  tragus;  **  *,  fissures  in  the  cartilage  of  the  external 
auditory  canal. 

opposite  to  this,  across  the  mouth,  or  meatus,  of  the  auditory 
canal,  is  a  similar  projection,  called  the  anti-tragus.  The  great- 
est concavity  of  the  auricle  is  called  the  concha,  from  a  Greek 
word  meaning  concave  shell.  This  concavity  passes  into  the 
meatus  auditorius  externus,  or  outer  opening  of  the  ear.  Above 
the  concha,  and  separated  from  it  by  a  projection,  is  a  depres 
sion  of  a  triangular  shape,  fossa  triangularis. 

Elastic  fibrous  bands,  springing  from  the  malar  bone  and 


MUSCLES   OF  THE  AURICLE.  83 

mastoid  process,  fasten  the  auricle  in  its  position,  and  allow  it 
a  certain  mobility.  The  auricle  is  completely  covered  by  the 
common  integument  of  the  body.  This  integument  is  more 
firmly  adherent  to  the  anterior  surface  of  the  cartilage  than  to 
the  posterior,  and  from  it,  at  the  extremity  of  the  ear,  a  projec- 
tion or  tip,  called  the  lobe,  is  formed.  The  lobe  or  lobule  con- 
tains no  cartilage,  only  fat  and  tough  connective  tissue.  It  is 
also  poorly  supplied  with  blood  and  nerves,  and  is  consequently 
not  very  sensitive.  It  is  very  distensible,  and  when  over-bur- 
dened by  heavy  ear-rings  may  become  very  much  elongated,  and 
thus  its  beauty  be  greatly  marred. 

In  rare  cases  serious  inflammatory  reaction  follows  the 
usually  harmless  operation  of  piercing  the  ears  for  the  wearing 
of  ear-rings.  Gruber '  observed  that  the  lobe  contained  cartilag- 
inous structure  in  one  case  of  this  kind  that  he  observed  in  his 
practice.  He  thinks  that  the  inflammation  was  due  to  a  wound- 
ing of  the  perichondrium. 


MUSCLES  OF  THE  AURICLE. 

There  are  three  muscles  which  move  the  auricle,  and  which 
are  attached  to  the  surrounding  parts.     They  .are — 
I.  Levator  or  Attollens  auriculam. 
II.  Attrahens  auriculam. 
III.  Retrahens  auriculam. 

They  are  placed  immediately  beneath  the  skin.  In  man  they 
are  usually  rudimentary  ;  but  they  are  the  analogues  to  certain 
large  and  important  muscles  in  some  of  the  mammalia. 

Some  persons,  and  especially  those  whose  hearing  has  be- 
come impaired  from  chronic  aural  disease,  acquire  considerable 
power  in  employing  these  muscles,  as  well  as  the  intrinsic  ones. 
I  have  often  observed  their  action^when  patients  were  listening 
for  the  ticking  of  a  watch,  which  was  being  gradually  ap- 
proached to  the  ear,  and  it  may  be  observed  when  such  persons 
are  attempting  to  hear  distant  sounds. 

The  levator  is  the  largest  of  the  three  muscles.  It  is  thin  and 
fan-shaped.  It  arises  from  the  aponeurosis  of  the  occipito-fron- 
talis,  and  its  fibres  converge  to  be  inserted  into  the  upper  part 
of  the  auricle. 

The  attrahens  auriculam  is  the  smallest  of  the  three.  It 
arises  from  the  lateral  edge  of  the  aponeurosis  of  the  occipito- 
frontalis  muscle.  Its  fibres  converge  and  are  inserted  in  front 

1  Lehrbuch,  p.  61. 


84  MUSCLES   OF  THE   AURICLE. 

of  the  helix.  This  muscle  is  separated  by  the  temporal  fascia 
from  the  temporal  artery  and  vein. 

The  retrahens  auriculam  consists  of  two  or  three  bundles  of 
fibres,  which  arise  from  the  mastoid  process.  They  are  inserted 
into  the  lower  part  of  the  cranial  surface  of  the  concha. 

The  names  of  these  muscles  indicate  their  action  :  the  levator 
slightly  lifts  the  auricle,  the  attrahens  draws^t  forward  and  up- 
ward, and  the  retrahens  draws  it  backward. 

Hyrtl  states  that  no  brute  has  a  lobe  as  a  part  of  the  auricle, 
and  that  none  of  the  mammals  living  in  water  have  an  auricle. ' 


INTRINSIC  MUSCLES. 

The  auricle  has  also  a  set  of  muscles  which  are  contained 
within  its  structure ;  intrinsic  muscles,  as  they  are  called  by 
several  authors.  With  a  single  exception  these  muscles  run  be- 
tween different  parts  of  the  cartilage  of  the  auricle  and  of  the 
auditory  canal. 

They  are  all  muscles  of  animal  life,  but  they  are  very  slightly 
developed,  and  are  therefore  pale,  and  thin,  and  flat.  They  lie 
closely  upon  the  cartilage,  and  are  inserted  into  its  fibrous  cov- 
ering by  means  of  short  tendinous  fibres.  They  are  sometimes 
absent.  It  is  possible,  although  not  certain,  that  they  always 
exist  at  birth,  but  that  they  subsequently  atrophy  from  want  of 
use.  Two  of  these  intrinsic  muscles  of  the  auricle  belong  to  the 
cartilage  of  the  auditory  canal,  the  remainder  to  the  auricle. 
The  former  occasionally  run  over  into  the  latter. 

1.  TRAGICUS. — This  muscle  lies  on  the  anterior  surface  of  the 
anterior  wall  of  the  cartilage  of  the  auditory  canal,  near  the 
upper  and  the  lateral  border.     It  is  quadrangular  in  shape,  and 
nearly  as  long  as  it  is  broad.     It  is  composed  of  parallel  fibres 
running  nearly  in  a  vertical  direction.     (See  Fig.  23,  4.) 

2.  ANTI-TRAGICUS.  —  This  muscle  lies  on  the  posterior  sur- 
face of  the  posterior  wall  of  the  cartilage  of  the  meatus.    (See 
Fig.  23,  5.) 

3.  HELICIS  MINOR. — Henle  says  that  this  is  the  most  con- 
stant of  the  muscles  of  the  auricle,  and  that  it  is  often  the 
strongest  of  the  intrinsic  muscles.     It  is  a  fan-shaped  muscle, 
and  is  found  on  the  lateral  surface  of  the  helix  between  its  root 
and  spine.     (Fig.  23,  3.) 

4.  HELICIS  MAJOR. — This  muscle  runs  over  the  anterior  mar- 
gin of  the  helix,  and  is  only  loosely  connected  with  it,  and  passes 

1  Lehrbucli  der  Anatomic  des  Menschen,  Bd.  II.,  p.  517. 


MUSCLES   OF   THE   AURICLE. 


85 


over  by  a  kind  of  tendinous  termination  into  the  levator  of  the 
auricle.     (Fig.  23,  2.) 

5.  TRANSVERSUS  AURICULA. — Transverse  Muscle  of  the  Au- 
ricle.— This  muscle  consists  of  fibres  which  are  not  very  thickly 
combined  with  loose  connective  tissue  fibres,  that  run  on  the 
posterior  surface  of  the  auricle  from  the  scaphoid  fossa  to  the 
concha  over  the  deep  furrow  corresponding  to  the  anti-helix. 
<Fig.  24.) 

6.  OBLIQUE  MUSCLE  OF  THE  AURICLE.— Obliquus  Auriculae. — 


FIG.  23.— Muscles  of  the  External  Ear  (after  Henle).  J/J  meatus  auditorius  externus ;  If", 
•spine  of  the  helix  ;  1,  attollens,  or  levator  auriculam  ;  2,  helicis  major  ;  3,  ht-licis  minor ;  4, 
tragicus ;  5,  anti-tragicus. 

This  muscle  bridges  over  the  furrow  on  the  posterior  surface  of 
the  auricle,  which  corresponds  to  the  prominence  on  the  surface 
of  the  cartilage  that  forms  the  lower,  sharp  root  of  the  anti- 
helix.  (See  Fig.  24,  O.m.) 

7.  DILATOR  OF  THE  CONCHA. — Musculus  incisurce  majoris  au- 
riculce  Santorini. — Sometimes  the  above-named  muscle  is  found 
on  the  tragus.  Hyrtl1  has  found  it  arising  from  the  anterior 

1  Hyrtl,  loc.  cit.,  p.  518. 


86  BLOOD-VESSELS   OF   THE   AURICLE. 

circumference  of  the  external  meatus,  whence  it  runs  downward 
and  outward  to  the  lower  border  of  the  tragus,  which  it  draws 
forward,  and  thus  enlarges  the  space  of  the  concha.  The  same 
author  says  that  he  knows  of  no  instance  of  the  voluntary 
change  in  form  of  the  auricle  by  the  action  of  this  muscle. 

"The  power  of  moving  the  auricle  as  a  whole,  is,  however, 
by  no  means  very  rare.  Haller  speaks  of  many  such  cases,  and 
B.  S.  Albin,  the  greatest  anatomist  of  the  eighteenth  century, 
used  to  take  off  his  wig  at  his  lectures,  to  show  his  students  how 
easily  he  could  move  the  muscles  of  the  auricle." 

Duchenne  and  Ziemssen,1  .by  means  of  faradization,  found 


E.s. 


T.a. 


C.m. 


C.c.  C.fi. 


FIG.  24. — View  of  the  Cartilage  and  Muscles  on  the  Posterior  Surface  of  the  Auricle  (after 
Henle).  E.s.,  elevation  made  by  scaphoid  fossa ;  U.c.,  elevation  formed  by  concha;  O.m., 
oblique  muscle;  E.f.t.,  eminence  made  by  fossae  triangularis ;  T. a.,  transversus  auriculae; 
(7.m.,  cartilage  of  the  external  auditory  canal ;  *,  attachment  to  the  edge  of  the  osseous 
canal;  (?.c.,  cartilage  of  the  auricle  ;  C.h.,  cauda  helicis. 

that  the  muscles  of  the  cartilage  of  the  meatus  narrowed  the 
incisura  auris,  and  thus  the  canal  leading  into  the  ear,  prevent- 
ing a  portion  of  the  sound  undulations  from  reaching  the  mem- 
brana  tympani,  while,  according  to  Duchenne,  the  helicis  major 
and  minor  lift  up  the  helix,  and  thus  favor  the  access  of  the 
sound  waves. 

BLOOD-VESSELS  OF  THE  AURICLE. 

Arteries  : 

1.  Posterior  auricular,  from  the  external  carotid. 

2.  Anterior  auricular,  from  the  temporal. 

1  Henle,  loc.  cit.,  p.  729. 


NERVES   AND   PHYSIOLOGY   OF  THE   AURICLE.  87 

(The  temporal  is  the  smaller  of  the  two  terminal  branches  of 
the  carotid.) 

3.  An  auricular  branch  of  the  occipital. 

It  will  thus  be  seen  that  the  blood-supply  of  the  auricle  is 
entirely  from  the  external  carotid  artery. 

The  veins  of  the  external  ear  empty  in  part  into  the  temporal 
vein,  as  well  as  into  the  external  jugular,  or  into  the  posterior 
facial  vein. 

NERVES  OF  THE  AURICLE. 

The  nerves  are  the — 

1.  Auricularis  magnus,  from  the  cervical  plexus.    The  cer- 
vical plexus  is  formed  by  the  anterior  branches  of  the  four  upper 
cervical  nerves. 

2.  Posterior  auricular,  from  the  facial. 

3.  An  auricular  branch  of  the  pneumogastric. 

4.  An  auriculo- temporal  branch  of  the  inferior  maxillary 
nerve. 

The  branches  of  the  cervical  plexus  are  on  the  posterior  side 
of  the  auricle. 

PHYSIOLOGY. 

The  exact  functions  of  the  auricle  still  remain  in  doubt.  We 
do  not  yet  know  to  what  extent,  if  any,  the  perception  of  the 
point  of  origin  of  sound,  or  the  conduction  of  sound  to  the 
membrana  tympani  are  assisted  by  the  muscles  of  this  part.  Ac- 
cording to  Hensen,1  the  results  of  experiments  as  yet  made  are 
contradictory.  Those  that  indicate  much  importance  to  the 
functions  of  the  auricle  are  of  doubtful  significance,  while  those- 
that  indicate  tljat  the  auricle  is  what  we  may  call  a  rudimentary 
part  are  more  positive.  In  1832  Esser 2  showed  that  the  reflec- 
tion of  sound-waves  from  the  individual  parts  of  the  auricle  do- 
not  assist  much  to  their  entrance  into  the  auditory  canal.  It 
was  also  observed  by  Harless,2  that  the  perception  of  sound  was 
not  weakened  when  a  long  glass  tube  was  placed  tightly  in  the 
passage,  even  when  the  body  causing  the  sound  lay  far  out- 
side of  the  direction  of  the  axis  of  the  canal.  Mach's 3  experi- 
ments also  showed  that  the  different  parts  of  the  drum-head 
were  not  differently  affected  according  to  the  direction  of  the 
sound.  Schneider's  experiments  are  even  more  positive  against 


1  Handbuch  der  Physiologic,   von  L.  Hermann.     Geho'r  von  V.  Hensen,  p.  23, 
Leipzig,  1880. 

2  Hensen,  loc.  cit. 

3  Archiv  fur  Ohrenheilkunde,  S.  72.    1874. 


88  PHYSIOLOGY   OF   THE   AUEICLE. 

the  influence  of  the  auricle.  He  filled  the  depressions  of  the 
auricle  within  and  without  with  wax,  only  leaving  the  canal 
free.  The  canal  then  being  directed  toward  the  source  of  sound, 
tones  were  rather  intensified  than  weakened.  Henseii  concludes 
from  Schneider's  observations,  that  the  direction  of  the  auricle 
toward  the  source  of  sound,  has  less  influence  upon  the  distinct- 
ness of  perception  than  does  the  opening  of  the  canal  with  a 
good  round  meatus.  Sounds,  according  to  the  same  author,  are 
most  distinctly  perceived,  when  they  fall  upon  the  ear  sideways. 
It  remains  an  open  question  if  vibrations  of  more  than  one 
thousand  times  a  second  can  be  concentrated  on  the  auricle  by 
reflection.  On  the  other  hand,  Rhine,  experimented  upon  an 
auricle  filled  with  dough,  and  he  found  the  tick  of  a  watch  was 
heard  further  when  the  auricle  was  uncovered.  Politzer '  thinks 
that  the  concha  is  the  important  part  of  the  auricle  in  assisting 
the  hearing.  He  found,  on  examination  of  persons  hard  of  hear- 
ing, that  the  limit  of  audition  was  nearer  the  head  as  tested 
with  the  metronome,  when  the  concha  was  covered  by  a  stiff 
piece  of  paper,  while  no  alteration  in  the  hearing  distance  was 
observed  if  the  other  depressions  of  the  auricle  were  covered. 
Politzer  also  regards  the  tragus  as  of  great  importance  for  the 
reflection  of  waves  of  sound  that  strike  the  auricle.  Kiipper 2 
denies  that  the  auricle  has  any  influence  upon  the  ear  in  the 
way  of  reflecting  the  waves  of  sound,  or  as  an  elastic  body 
vibrating  with  the  waves  and  conducting  them  directly  to  the 
deeper  parts.  He  insists  that  Boerhaave's  notion  that  the  un- 
dulations, after  long  wandering,  are  united  in  the  auditory  canal 
by  the  depressions  of  the  auricle  is  incorrect,  and  he  believes 
that  the  auricle  cannot  perform  any  such  office,  but  that  a  mem- 
brane like  the  membrana  tympani  is  necessary  for  this.  He 
reminds  his  readers  that  birds  whose  hearing  power  in  every 
respect  exceeds  that  of  man,  have  no  auricle.  Kiipper  adopts 
the  theory  of  Darwin  and  Haeckel,  and  classes  the  auricle 
among  the  organs  that  evolution  has  rendered  useless  in  man 
except  as  appendages,  in  this  case  as  an  ornamental  one.  Mach  3 
confirms  Kiipper's  views,  but  he  considers  that  the  auricle  is 
a  resonator  for  high  tones,  such  as  the  rustling  of  the  grass, 
the  leaves,  sounds  important  to  animals,  but  even  this  function 
he  believes  only  exists  to  a  slight  degree  in  man.  Burnett 4 
claims  to  have  anticipated  Mach's  views  in  regard  to  the  reson- 


1  Text-book,  p.  61.    Translation. 

J  Archiv  fur  Ohrenheilkunde,  Vol.  IX.,  p.  76.  Neue  folge,  Vol.  III. 

3  Loc.  cit. 

4  Text-book,  p.  34. 


PHYSIOLOGY   OF   THE   AURICLE.  89 

Bating  capacity  of  the  auricle,  but  the  experiments  of  Burnett 
include  the  external  auditory  canal.  In  the  opinion  of  the  latter- 
named  author,  the  absence  of  an  auricle  in  birds  does  not  argue 
against  its  utility  as  a  resonator  in  man,  for  the  wave  lengths 
of  the  high  notes  used  by  birds  are  so  short  that  they  resound 
well  in  their  shallow  auditory  canal.  Dr.  Sexton,1  as  the  result 
of  some  experiments  upon  the  living  subject,  concludes  that  the 
range  of  hearing  for  the  tuning-fork  is  increased  in  some  per- 
,sons,  when  the  occipito-f  rontalis  muscle  is  contracted.  He  thinks 
that  this  muscle  acts  as  an  auxiliary  to  the  attollens  auriculam 
.and  attrahens  auriculam.  As  the  result  of  one  dissection  of  the 
human  subject,  he  found  that  traction  of  the  deep  temporal  fascia 
moved  the  auricle  freely.  He  also  found  that  when  alternate 
tension  and  relaxation  were  practised  on  the  same  fascia,  the 
drum-head  also  became  tense  or  relaxed,  the  motion  being  visi- 
ble. The  anatomists  describe  the  occipito-frontalis  as  a  muscle 
which  occasionally  has  muscular  slips  extending  to  the  pos- 
terior auricular  muscle.  It  is  possible  that  in  exceptional  cases 
the  action  of  the  former  muscle  would  affect  the  auricle  as  well. 
The  action  of  the  deep  temporal  fascia  upon  the  drum-head,  as 
described  by  Dr.  Sexton,  is  with  difficulty  conceived  of,  when  we 
remember  that  the  drum-head  is  nearly  surrounded  by  bone,  and 
only  connected  through  the  handle  of  the  malleus  with  soft 
parts — the  tensor  tympani  muscle.  How  the  action  of  this  mus- 
cle can  be  influenced  by  traction  of  the  deep  temporal  fascia,  I 
cannot  conceive. 

The  relations  of  the  muscles  of  the  auricle  to  the  occipito- 
frontalis,  are  well  shown  in  the  cut  from  Sappey  on  the  next 
page.  In  the  exceptional  cases  in  which  the  power  of  moving 
the  occipital  and  frontal  muscles,  as  the  occipito-frontalis  is 
called  by  the  French  anatomists,  it  is  readily  seen  that  the  auri- 
cle may  also  be  moved. 

A  careful  study  of  all  that  has  been  written  upon  the  physi- 
ology of  the  auricle,  as  well  as  observations  upon  the  living  sub- 
ject, render  it  tolerably  clear  to  my  mind,  that  the  auricle  is 
really,  as  Darwin  and  Hackel  claim,  only  a  rudimentary  .organ, 
and  not  of  value  in  hearing,  except  under  exceptional  circum- 
stances. Even  if  the  tick  of  a  watch  be  heard  further,  as  Rinne 
and  others  show,  when  the  concha  be  uncovered,  this  by  no 
means  proves  that  conversation  is  heard  further  by  its  aid,  since 
the  test  by  the  tick  of  a  watch  is  a  fallacious  one  as  compared 
with  that  by  human  speech  or  the  notes  of  music.  It  is  probable, 
however,  that  the  rudimentary  capacity  of  the  auricle  as  a  res- 


Medical  Record,  November  17,  1883. 


90 


MUSCLES   OF   THE   AUKICLE. 


onator  is  greatly  increased  by  placing  the  hand  behind  it,  and 
that  those  whose  hearing  is  impaired,  may  sometimes  increase 
their  hearing  power  in  this  way.  If  this  were  not  the  case,  the 
human  race  would  have  long  ago  abandoned  the  habit. 


FIG.  25. — The  Muscles  of  the  Head  (from  Sappey).  1,  Posterior  auricular  muscle,  having" 
two  sets  of  attachments,  a  superior  very  short,  an  inferior  much  longer ;  2,  superior  auricular 
muscle  ;  3,  anterior  auricular  muscle  ;  4,  occipital  muscle ;  5,  section  of  the  aponeurosis  which 
extends  from  the  occipital  muscle  to  the  superior  auricular  ;  6,  aponeurosis,  extending  from  the 
occipital  and  running  under  the  inferior  surface  of  the  auricular  superior ;  7,  superior  fibres 
of  the  superficial  temporal  muscle,  situated  at  the  termination  of  the  two  parts  coming  from 
the  occipital  muscle  ;  8,  lower  fibres  of  the  superficial  temporal,  united  to  the  anterior  auricu- 
lar by  a  fibrous  band  which  forms  a  part  of  the  epicranial  aponeurosis. 


EXTERNAL  AUDITORY  CANAL. 

The  canal  leading  from  the  auricle  to  the  membrana  tym- 
pani  consists  of  two  portions,  an  outer  part,  which  is  formed  of 
cartilage,  and  an  inner,  which  is  of  bone. 

Its  external  opening,  which  is  formed  by  the  cartilaginous 
portion,  corresponds  anteriorly  and  below  with  the  margin  of 
the  external  ear.  Behind,  it  is  demarcated  by  the  ridge  which 
connects  the  anterior  border  of  the  auricle  with  the  margin  of 


EXTERNAL    AUDITORY    CANAL. 


91 


the  osseous  meatus ;  above,  it  is  bounded  by  the  root  of  the 
helix. 

Inasmuch  as  the  membrana  tympani  is  not  on  a  plane  per- 
pendicular to  the  walls  or  sides  of  the  canal,  these  do  not  ex- 
tend equally  far  inward.  The  anterior  and  inferior  wall  is  the 
longest.  It  thus  becomes  impossible  to  give  an  exact  measure- 
ment of  the  canal  which  can  be  applied  to  all  ears.  The  canal  is 
also  curved,  and  its  cartilaginous  portion  is  very  elastic. 


CM 


cc 


CM 


FlG.  26. — Section  through  the  External  Meatus  and  the  Ear  at  the  Point  of  Junction  of 
the  Cartilage  of  the  Auricle,  CC,  with  that  of  the  Auditory  Canal  (after  Henle).  A  small 
portion  of  the  upper  wall  of  the  latter  remains  as  a  narrow  band,  CM' ;  CM",  lower  wall  of 
the  cartilage  of  the  external  meatus  ;  H",  spine  of  the  helix  ;  L,  lobe  of  the  ear  ;  *,  fibrous 
lip  of  the  border  of  the  osseous  meatus  ;  1,  epicranius  temporalis  muscle  ;  2,  levator  anricu- 
laris  ;  3,  temporal  muscle  ;  4,  upper  wall  of  the  osseous  canal ;  5,  cavity  of  the  tympanum  ; 
6,  membrana  tympani ;  7,  stapes  bone  ;  8,  vestibule  ;  9,  meatus  auclitorius  internus  and  acous- 
tic nerve  ;  10,  lower  wall  of  the  osseous  meatus  ;  11,  parotid  gland. 

The  first  curvature  is  described  by  Henle  as  zigzag  in  shape, 
and  is  well  shown  in  the  two  cuts  from  his  work  on  anatomy. 
This  curvature  is  constant.  These  curvatures  may  be  overcome, 
and  the  outer  portion  of  the  canal  rendered  nearly  if  not  quite 
straight,  by  drawing  the  auricle  upward  and  backward.  The 
cartilaginous  portion  of  the  canal  is  interrupted,  especially  on  its 
inferior  wall,  by  gaps  and  fissures — the  so-called  Incisurce  San- 
torini.  These  gaps  are  filled  up  by  fibrous  tissue.  The  osseous 


'92 


EXTERNAL    AUDITORY   CANAL. 


portion  is  an  integral  portion  of  the  temporal  bone,  and  has  a 
groove  for  the  insertion  of  the  membrana  tympani.  (Sulcus  pro 
membrana  tympani. — Hyrtl.) 

The  length  of  the  canal,  according  to  Hyrtl,  varies  from  9 


FIG.  27. — Horizontal  Section  of  the  Head,  through  the  External  Auditory  Canal  (after 
Henle).  1,  Cartilage  of  the  external  auditory  canal ;  *,  fissure  in  the  cartilage  ;  2,  cartilage  of 
the  auricle ;  3,  tuberculum  articulare  of  the  lower  jaw  ;  4,  fossa  mandibularis  ;  5,  membrana 
tympani  ;  6,  cavity  of  the  tympanum  ;  7,  vestibule  ;  8,  transverse  sinus  ;  9,  mastoid  cells. 

lines  to  one  inch.  The  average  length  of  the  canal,  according 
to  Troltsch,1  is  about  24  millimetres.  The  cartilaginous  portion 
forms  about  one-third  of  this,  or  8  mm.,  and  the  osseous  canal 
the  remaining  two-thirds,  or  16  mm. 

The  angle  which  the  upper  wall  of  the  canal 
forms  with  the  membrana  tympani,  is  an  obtuse 
one ;  but  that  between  the  lower  wall  and  the 
drum-head  is  acute  ;  it  is  one  of  about  45°. 

The  width  of  the  canal  varies  as  well  as  the 
length.     It  is  widest  at  the  junction  of  the  osseous 
with  the  cartilaginous  canal,  and  next  to  the  mem- 
brana tympani. 
The  casts  made  by  Dr.  F.  M.  Wilson,  as  here  delineated,  con- 
firm Hyrtl's  and  Sappey's  moulds  of  wax,  and  show  that  the 
canal  is  a  spiral  turning  anteriorly  inward  and  downward. 


FIG.  28.—  Annu- 
1  u  s  Tympanicus 
(actual  size,  from 
Professor  D  a  r- 

1  ing's  museum). 


1  Treatise  on  the  Ear,  second  American  edition,  p.  18. 


EXTERNAL    AUDITORY   CANAL. 


The  auditory  canal  is  lined  by  integument,  and  not  by  mu- 
cous membrane.  Hence  it  is  not  correct  to  speak  of  a  catarrh, 
of  the  external  auditory  canal.  This  integument  is  merely  a 
continuation  of  that  of  the  general 
surface  of  the  body.  The  nearer  it 
approaches  the  membrana  tympani, 
the  thinner  it  becomes,  and  finally  it 
covers  the  drum-head  as  a  very  thin 
layer. 

"  The  integument  of  the  cartilag- 
inous portion  of  the  canal  is  1£  mm. 
thick,  and  contains  soft  hairs,  with 
their  sebaceous  glands,  the  cerumi-  *nd  AdJacent  Parts  (actual  size)- 

-.         ,  ,        ,.,,,      ~    ,    .       .,  ,       External  auditory  canal;  2,  mastoid 

nous  glands,  and  a  little  fat  in  its  sub-  cells.  3>  tvmpanic  cavity.  \  Eusta. 

CUtaneOUS  tissue.       In  the  OSSeOUS  part    chian  tube  ;    5,    fenestra  ovalis ;   6, 

Of  the   Canal,  the  integument   is   Only   P°sition  °f  membrana  tympani;  7, 
,1  .    -i  ,  i  /.,    i  posterior  opening  of  mastoid. 

0.1  mm.  in  thickness,  the  soft  hairs 

become  very  few,  and  the  ceruminous  glands  are  found  only  on 
the  posterior  upper  wall,  where  they  are  generally  seen,  even 
close  to  the  membrana  tympani.  Small  papillae  are  found 


FIG.  29.— Cast  of  Auditory  Canal 


FIG.  30. — Section  of  Left  Temporal  Bone  (actual  size,  from  Professor  Darling's  museum). 
1,  Styloid  process  ;  2,  carotid  canal ;  3,  promontory  ;  4,  floor  of  tympanic  cavity  over  carotid 
canal ;  5,  mastoid  cells ;  6,  external  auditory  canal. 

arranged  in  rows  under  the  cuticle,  and  also  a  corium  with 
.abundant  elastic  fibres,  of  which  the  lower  layers  pass  into  the 
periosteum." 1 

The  ceruminous  glands  are  like  the  sudoriparous  or  sweat 


1  The  Organ  of  Hearing.     J.  Kessel,  Strieker's  Manual,  p.  951.     Translated  by  J. 
Orne  Green. 


94  EXTERNAL   AUDITORY     CANAL. 

glands  in  their  development  and  secretion.  The  only  difference 
between  the  secretion  of  the  two  kinds  of  glands,  is  that  the 
ceruminous  glands  contain  some  coloring  matter.  (Cerumen  is 
probably  derived  from  cera  aurium. — Hyrtl.) 

The  substance  of  the  ceruniinous  glands  is  a  yellowish-white, 
rather  fluid  material,  which  consists  essentially  of  fat-globules, 
coloring  matter  and  cells  in  which  single  globules  of  fat  and 
coloring  matter  are  embedded ;  there  are  also  hairs  and  scales 
of  epidermis  from  lining  of  the  meatus  (Kessel).  When  the 
cerumen  has  remained  in  the  canal  for  a  long  time,  its  watery 
contents  are  lost  by  evaporation,  and  it  becomes  a  hard  mass. 

Sometimes  the  hairs  of  the  canal  grow  to  such  a  length  as 
to  obscure  the  view  of  the  meatus  and  the  drum-head.  In  such 
cases  I  have  been  obliged  to  remove  them  with  a  pair  of  curved 
scissors.  By  rubbing  upon  the  surface  of  the  membrana  tym- 
pani,  they  may  cause  a  tickling  sensation  in  the  ear  and  become 
a  source  of  annoyance.  Dr.  R.  F.  Weir  relates  such  a  case.1 

According  to  Buchanan,  an  author  who  laid  too  much  stress 
upon  the  part  which  the  cerumen  plays  in  the  economy,  there 
are  from  one  thousand  to  two  thousand  ceruminous  glands. 

The  child  at  birth,  and  for  some  time  after,  has  no  osseous 
meatus.  The  cartilaginous  portion  is  at  first  attached  to  a  mem- 
branous part,  just  as  it  is  afterward  to  the  osseous  portion. 

Gruber 2  thinks  that  there  is  a  very  narrow  rim  of  osseous  canal  in  the  last 
months  of  embryonal  life. 

In  the  newly  born  this  membranous  portion  constitutes  about 
one-half  of  the  canal .;  but  it  gradually  becomes  shorter  as  the 
bone  grows  outwardly.3 

This  ossification  proceeds  irregularly,  and  often  leaves  a  for- 
amen, which,  according  to  Troltsch,  has  been  mistaken  for  a 
pathological  condition,  the  result  of  caries.  An  inflammation 
of  the  meatus  in  a  young  child,  as  shown  by  the  same  author, 
might  readily  pass  through  this  foramen  to  the  maxillary  articu- 
lation or  parotid  gland. 

The  auditory  canal  of  the  dog  and  cat  are  closed  at  birth,  as 
are  their  eyelids.  There  is,  perhaps,  as  Troltsch  suggests,  an  an- 
alogous condition  in  the  closure  of  the  meatus  of  young  children 
with  vernix  caseosa,  and  the  approximation  of  the  walls  of  the 
meatus,  near  the  membrana  tympani. 

Some  birds  have  the  power  of  stopping  their  ears  by  a  kind  of 

1  Transactions  American  Otological  Society,  third  year. 
*  Monatsschrift  fur  Ohrenheilkunde,  Bd.  II.,  p.  67. 
4Tx6ltsch,  loc.  cit.,  p.  6. 


RELATIONS   OF   THE  AUDITORY   CANAL. 


95 


valve.  The  turkey  has  a  kind  of  erectile  tissue  projecting  into 
the  meatus.  so  that  it  can  close  the  ears  more  or  less  perfectly 
when  angry  (Troltsch). 


RELATIONS  OF  THE  AUDITORY  CANAL. 

The  cartilaginous  portion  is  bounded  anteriorly  and  inf  eriorly 
by  the  parotid  gland.  Cases  have  been  observed  where  abscesses 
of  the  parotid  have  discharged  into  the  auditory  canal,  through 
the  fissures  of  Santorini.  This  occurred  during  the  fatal  illness 
of  the  late  President  Garfield,  while  he  was  suffering  from  sup- 
purative  parotitis.  Enlargements  of  the  parotid  or  lymphatic 
glands  may  contract  the  calibre  of  the  canal  by  pressure. 

The  anterior  wall  is  also  in  relation  with  the  posterior  wall  of 
the  articular  fossa  of  the  inferior  maxillary  bone.  Hence  a  blow 


FIG.  31. — External  Surf  ace  Left  Temporal  Bone  (two-thirds  size).  2,  Mastoid  process  ;  3, 
zygomatic  process  ;  4,  styloid  process  ;  5,  external  auditory  canal ;  6,  glenoid  fossa  ;  7,  tym- 
panic process  ;  8,  vaginal  process  ;  9,  mastoid  foramen. 

upon  the  chin  may  produce  a  fracture  of  this  plate,  and  cause  a 
hemorrhage  from  the  ear.  The  thick  articular  cartilage  protects 
the  auditory  canal  and  temporal  bone  from  the  full  force  of  such 
a  blow. 

The  posterior  wall  is  made  up  by  the  mastoid  process  in  such 
a  way,  that  the  canal  is  only  separated  from  the  transverse  sinus 
by  two  thin  plates  of  osseous  tissue  and  the  air-cells  lying  be- 
tween them.  The  superior  wall  is  covered  on  its  upper  surface 
by  the  dura  mater,  and  forms  a  portion  of  the  floor  of  the  mid- 
dle fossa  of  the  skull  (Troltsch). 

The  wall  between  the  integument  of  the  canal  and  the  dura 
mater,  may  be  exceedingly  thin,  and  inflammations  of  the  mea- 
tus may  produce  disease  of  the  brain. 


96  EXTERNAL   AUDITORY    CANAL. 

The  auditory  canal  is  bounded  above  and  behind  by  portions 
of  the  mastoid  cells,  that  are  included  in  the  "middle  ear,"  so 
that,  strictly  speaking,  a  portion  of  the  mastoid  part  of  the 
middle  ear  is  situated  beyond  the  membrana  tympani.  Inflam- 
mations of  the  mastoid,  in  not  unfrequent  cases,  occur  with  no 
perforation  of  the  membrana  tympani,  and  the  pus  evacuates 
itself  in  the  auditory  canal.  The  importance  of  these  relations 
was  first  fully  pointed  out  by  Troltsch. 

BLOOD-VESSELS  OF  THE  AUDITORY  CANAL. 

1.  Posterior  auricular  artery,  which  also  supplies  the  auricle. 

2.  Deep  auricular,  from  the  internal  maxillary.     It  enters  at 
the  articulation  of  the  lower  jaw,  supplies  the  tragus,  and  then, 
gives  off  branches  to  the  canal. 

NERVES. 

1.  From  the  third  branch  of  the  tri-facial  or  fifth  nerve. 
These  enter  through  the  anterior  wall,  between  the  cartilaginous 
and  osseous  portions. 

2.  An  auricular  branch  from  the  pneumogastric,  which  en- 
ters the  anterior  wall  of  the  bony  canal. 

This  auricular  branch  was  first  described  by  Arnold  in  1828. 

The  effect  of  irritation  of  this  branch  is  often  seen  by  the 
cough  produced  when  the  aural  speculum  is  pressed  upon  it,  or 
when  the  part  is  touched  by  a  probe. 

PHYSIOLOGY. 

The  length  and  curvature  of  the  auditory  canal  prevent  the 
membrana  tympani  and  auditory  canal,  under  ordinary  circum- 
stances, from  being  injured  by  wind,  changes  of  temperature, 
and  the  like.  The  cerumen  probably  also  guards  against  the 
frequent  entrance  of  insects.  The  auditory  canal  increases  the 
power  of  tones  by  acting  as  a  resonator. ' 

1  Hensen,  loc.  cit. 


CHAPTER  IV. 

THE  MALFORMATIONS  AND  DISEASES  OF  THE  AURICLE. 

A  Finely  Formed  Auricle  an  Indication  of  Character. — Malformations. — Superfluous 
Auricles. —  Ely's  operation  for  Prominent  Auricles. — Tumors.  —  Angiomata. — 
Othsematomata.  — Perichondritis.  — Malignant  Growths.  — Syphilitic  Affections.  — 
Erysipelas. — Effects  of  Gout. 

A  FINELY  formed  auricle  is  justly  esteemed  one  of  the  marks  of 
personal  beauty.  The  celebrated  physiognomist,  Lavater,  also 
attached  considerable  importance  to  this  part  as  a  means  of  de- 
termining character.  A  humorous  German  critic,  quoted  by 
Voltolini,  in  speaking  of  Lavater's  ideas  of  physiognomy,  says : 
"  It  would  be  very  queer  of  Dame  Nature,  if  she  had  hung  every 
one's  character  on  the  nose,  so  that  any  one  who  was  a  master 
in  physiognomy  could  read  it.  Perhaps  fearing  this,  some 
people  shut  their  eyes  and  are  ashamed  to  look  one  in  the  face." 
A  French  author,  Dr.  Amedee  Joux,  quoted  by  Troltsch,  goes 
much  farther  than  Lavater  in  his  estimation  of  the  signification 
of  the  auricle.  Besides  the  part  which  it  plays  in  indicating  hu- 
man character,  he  claims  that,  more  than  any  other  organ  of  the 
body,  it  descends  with  its  particular  form  from  father  to  child, 
and  that  by  the  shape  of  the  auricle  we  may  be  assisted  in  deter- 
mining the  legitimacy  of  children,  and  the  conjugal  fidelity  of  a 
mother.  He  says,  "  Montre-moi  ton  oreille,je  te  diraiqui,  iu  es, 
d'ou  tu  viens,  et  ou  tu  vas,"  or,  as  we  should  say  in  English,  "  Let 
me  see  your  ear,  and  I  will  tell  you  who  you  are,  where  you  came 
from,  and  where  you  are  going." 

I  am  inclined  to  think  that  this  view  of  the  importance  of  the 
auricle  is  somewhat  fanciful.  Whatever  may  be  the  significance 
of  the  auricle,  as  regards  character  or  legitimacy,  its  perfect 
shape  has  very  little  to  do  with  the  power  of  hearing.  Whether 
it  lies  properly  fitted  to  the  head,  and  has  all  its  parts  of  helix, 
fossa  helicis,  beautifully  shaped,  or  whether  it  laps  over  like  that 
of  an  inferior  animal,  or  be  a  shapeless  appendage,  makes  very 
little  difference  in  the  power  of  hearing  music  or  the  human 
voice.  As  we  have  seen  in  the  discussion  in  the  preceding  chap- 
7 


98  MALFORMATIONS   OF  THE  AURICLE. 

ter,  the  functions  of  the  auricle  are  like  its  muscles — unimpor- 
tant and  rudimentary. 

We  may  conveniently  classify  the  prominent  affections  of 
the  auricle  as  follows  : 

1.  Malformations. 

2.  Tumors,  benign  and  malignant. 

3.  Syphilitic  diseases. 

4.  Othfematomata. 

5.  Perichondritis. 

6.  Eczema. 

7.  Effects  of  Gout. 

8.  Erysipelas. 


I.  —MALFORMATIONS. 

Many  of  the  so-called  malformations  are  the  natural  results 
of  ill-treatment  of  the  auricle.  Many  women,  especially  those 
of  the  lower  class,  cover  their  ears  so  tightly  with  their  hair,  cap 


FIG.  32. — Case  of  Prominence  of  Auricles. 


and  hood,  that  they  finally,  by  the  excessive  pressure,  flatten  out 
and  fill  up  the  natural  elevations  and  depressions  which  go  to 
make  a  finely  shaped  auricle.  Children's  auricles  are  sometimes 


PROMINENCE   OF   AURICLES.  99 

injured  in  their  passage  from  the  womb  to  the  world.  Boys  often 
get  into  the  bad  habit  of  pressing  their  caps  down  upon  their 
ears.  They  thus  cause  them  to  lap  over  and  give  them  the  un- 
sightly appearance  known  as  "  dog  ears."  A  boy,  twelve  years 
of  age,  presented  himself  in  1881  at  the  clinic  in  the  Manhattan 
Eye  and  Ear  Hospital  held  by  myself  and  Dr.  Ely,  complaining 
that  he  was  ridiculed  by  his  companions  on  account  of  the 
prominence  of  his  ears.  He  desired,  if  possible,  that  an  opera- 
tion be  performed  which  should  relieve  him  from  this  annoy- 
ance. The  accompanying  cuts  give  a  good  idea  of  the  degree  of 
the  deformity  of  one  side.  It  was  equally  deformed  upon  the 
other  side  until  relieved  by  Dr.  Ely's  operation.  The  second  cut 


FIG.  33. — Case  of  Prominence  of  Auricles. 

gives  a  good  idea  of  the  back  view  of  the  auricles  before  and 
after  the  operation. 

Dr.  Ely  describes  his  operation  as  follows:1  The  right  ear 
was  first  operated  upon.  An  incision  was  made  through  the 
skin,  along  the  entire  length  of  the  furrow  formed  by  the  junc- 
tion of  the  auricle  with  the  side  of  the  head  posteriorly.  This 
was  joined  at  each  end  by  a  curved  incision  carried  over  the 
posterior  surface  of  the  auricle,  and  the  skin  and  subcutaneous 
tissue  included  by  tnese  incisions  were  dissected  off.  Two  in- 
cisions, nearly  parallel  to  the  former  ones,  were  then  carried 
through  the  cartilage,  and  an  elliptical  piece  of  the  latter,  meas- 


1  Archives  of  Otology,  Vol.  X. ,  No.  2,  p.  97. 


100  PROMINENCE   OF  AURICLES. 

uring  1£  inch  by  £  inch,  was  removed.  The  pieces  of  excised 
skin  were  considerably  larger  than  this.  The  edges  of  the; 
wound  were  then  united  by  ten  sutures,  of  which  seven  only 
included  the  skin,  while  three  passed  through  both  skin  and  car- 
tilage. Owing  to  the  natural  folds  of  the  cartilage,  it  was  im- 
possible to  secure  perfect  coaptation  on  the  anterior  surface  of 
the  auricle,  and  a  small  space  was  here  left  to  heal  by  granula- 
tion. The  dressing  consisted  of  absorbent  cotton  and  a  bandage. 
Healing  ensued  with  very  little  pain  or  swelling — the  posterior 
incision  united  by  first  intention  and  the  anterior  wound  by 
granulation.  The  sutures  were  removed  on  the  fourth  day. 

Dr.  Ely  varied  the  operation  upon  the  left  ear  somewhat,  by 
transfixing  it  with  a  scalpel  and  excising  a  piece  of  cartilage 
of  the  desired  size  and  shape,  together  with  its  overlying  skin. 
Additional  skin  was  then  removed  from  the  posterior  surface. 
Three  sutures  were  used  through  the  cartilage  on  its  anterior 
surface  and  one  on  the  posterior.  The  dressing  was  absorbent 
cotton  and  a  bandage.  Complete  union  by  first  intention  was 
not  obtained,  but  the  result  was  as  satisfactory  as  in  the  first 
ear.  Ether  was  used  as  an  anaesthetic  for  both  operations.  The 
posterior  cicatrices  were  hidden  by  their  position,  and  those  on 
the  anterior  surface  are  hardly  noticeable.  The  hearing  was 
normal  before  and  after  the  operation.  The  boy  expressed  him- 
self as  entirely  satisfied  with  the  result,  and  came  of  his  own 
free  will  for  the  operation  on  the  second  ear,  some  weeks  after 
the  first  had  been  operated  upon. 

I  have  since  performed  the  operation  in  one  case,  in  the  man- 
ner which  Dr.  Ely  performed  his  first  operation,  and  I  append 
the  note  of  the  father  of  the  child,  a  physician,  as  to  the  result. 
Dr.  S writes  : 

DEAK  DOCTOR  : 

Before  the  operation  the  auricle  projected  at  the  extreme  point  li  inch  ; 
the  left  ear  1  inch.  Since  healing  the  projection  is  |.  There  is  a  red  cicatricial 
spot  on  the  auricle  that  shows,  but  would  not  ordinarily  be  observed.  He  is  so 
much  improved  that  people  would  not  now  notice  anything  unusual  about  the 
ears  ;  but  before,  both  being  prominent,  and  one  much  more  so  than  the  other, 
it  was  observed  by  every  one. 

The  detachment  of  the  auricle  is  by  no  means  a  formidable 
operation,  and  I  can  cordially  commend  Ely's  method  as  an  ex- 
cellent means  of  removing  the  deformity  Qf  prominent  auricles. 

ARRESTED  DEVELOPMENT— MICROTIA. 

There  is  a  class  of  malformations  of  the  auricle  which  has 
the  same  pathological  interest  with  other  forms  of  arrested  de- 


MIOEOTIA. 


101 


velopment,  such  as  spina  bifida,  coloboma  iridis,  etc. ,  but  unfor- 
tunately they  are  also  cases  for  which  our  art  can  do  nothing. 
I  refer  to  those  cases  in  which  the  auricle  is  congenitally  ab- 
sent, or  where  it  exists  only  in  a  rudimentary  form.  In  such 
instances  the  cartilaginous  and  osseous  auditory  canals  are 
usually  also  wanting,  but  the  middle  and  internal  ear  may  be 
well  developed. 

There  are  cases,  however,  in  which  the  whole  ear  is  undevel- 
oped. The  deformity  usually  affects  but  one  ear,  but  both  ears 
are  sometimes  similarly  affected.  Attempts  have  been  made  by 
surgeons '  to  make  a  passage  to  the  drum-head  and  middle  ear, 


FIGS.  34,  35. — Deformity  of  Auricles. 

but  as  yet  they  have  failed.  It  is  probable  that  the  middle  ear 
is  not  in  a  normal  condition,  for  the  impairment  of  hearing  is 
usually,  if  not  always,  greater  than  could  be  explained  by  the 
mere  absence  of  a  canal  leading  to  the  membraiia  tympani. 

The  illustrations  seen  above,  and  the  account  of  one  case,  give 
a  fair  idea  of  these  deformities,  for  which  art  has  as  yet  done 
very  little.  I  have  never  seen  any  artificial  ears  that  served  any 
good  purpose  in  masking  the  deformity.  In  females,  the  hair 
can  be  made  to  do  very  well  in  this  respect.  Fortunately,  but 
one  ear  is  usually  deformed. 

Superfluous  auricles  sometimes  occur,  just  as  do  supernu- 
merary toes  and  fingers.  They  are  objects  of  anatomical  curi- 


102  DEFORMITY  OF   THE  AUKICLES. 

osity  rather  than  of  therapeutical  interest.  Beck1  details  a 
number  of  cases  in  which,  by  freaks  of  Nature,  the  auricle  was 
placed  on  the  back,  the  shoulder,  and  near  the  angle  of  the 
mouth. 

The  case  of  which  an  illustration  is  given  on  the  preceding 
page,  consulted  me  in  1881,  with  reference  to  a  relief  of  the  de- 
formity. He  was  thirty  years  of  age,  and  was  born  with  a  rudi- 
mentary and  deformed  auricle  on  each  side.  There  was  also  bony 
closure  of  the  canal  on  each  side.  He  understood  loud  conversa- 
tion some  four  or  five  feet  away.  He  heard  musical  sounds  well. 
In  this  case  it  is  evident  that  the  deformity  is  confined  tothe  outer 
and  middle  ear.  The  patient,  as  is  seen  by  the  cut,  is  a  well-de- 
veloped man.  He  has  learned  a  trade  and  succeeds  well  in  it. 
Dr.  David  Hunt8  reports  three  cases  from  the  practice  of  Dr. 
Blake,  in  which  the  deformity  of  the  auricle  and  the  absence  of 
the  auditory  canal  constituted  the  disease  of  the  ear.  Hunt  be- 
lieves that  these  malformations  originate  in  the  auricle.  He 
regards  "the  association  of  the  malformation  of  the  auricle  as 
due  to  the  interruption  of  a  natural  order  of  events,  according  to 
which  a  certain  stage  of  development  of  the  auricle  precede? 
the  formation  of  the  meatus  (auditory  canal). 

I  am  indebted  to  Dr.  "William  Hunt,  of  Philadelphia,  for  an  account  of  de' 
formities  of  the  auricle  occurring  in  five  children  of  one  family.  The  first  child, 
instead  of  an  auricle,  had  a  little  pedunculated  growth  in  front  of  the  tragus. 
The  second  had  the  same  defect,  and  two  similar  growths  in  front  of  the  tragus. 
In  a  third,  the  upper  part  of  the  auricle  was  turned  over  forward.  A  fourth  had 
one  auricle  half  an  inch  longer  than  the  other.  A  fifth  child,  whom  Dr.  Hunt 
saw  when  it  was  two  or  three  weeks  old,  is  described  by  him  as  having  "  no  ear 
at  all.  There  were  mere  nodulated  small  masses  of  cartilage  and  skin,  with  a 
little  point  which  seemed  to  be  an  opening,  but  was  a  mere  cul-de-sac  not  more 
than  an  eighth  of  an  inch  deep."  Dr.  Hunt  saw  the  child  again  in  a  few  months, 
but  the  auricles  had  not  developed.  It  was  difficult  to  tell  whether  the  child 
heard  or  not.  The  monthly  nurse  was  positive  in  her  opinion  that  babies  with 
good  ears  hear  at  once,  and  this  coincides  with  the  opinion  of  most  nurses,  as 
Dr.  Hunt  and  I  agree,  but  as  I  shall  discuss  this  question  in  speaking  of  deaf 
muteism,  I  merely  allude  to  it  here.  There  was  but  one  child  in  this  family  of 
six  in  whom  there  was  a  perfect  auricle,  although  the  children  were  perfect  in 
other  respects. 

FISTULA  OF  AURICLE. 

I  have  seen  two,  if  not  more  cases  of  fistulous  openings  in  the 
auricle,  which  were  said  to  be  congenital  and  from  which  pus  es- 
caped at  certain  times.  In  one  case  these  fistulse  were  associated 

1  Krankheiten  des  Gehororgans,  p.  108. 

1  American  Journal  of  Otology,  Vol.  III. ,  No.  1 . 


TUMORS   OP  THE   AURICLE.  103 

with  one  just  above  the  thyroid  body.  I  advised  incision  of  the 
fistulse  and  the  application  of  tincture  of  iodine  or  bichloride  of 
mercury  to  the  open  canals  thus  made,  but  in  neither  instance 
was  my  advice  followed.  Indeed,  I  only  saw  the  cases  inciden- 
tally, the  patients  having  consulted  me  for  another  form  of  aural 
disease,  apparently  not  connected  with  the  fistulous  ulcers.  The 
patients  seemed  to  fear  that  a  stoppage  of  the  periodical  dis- 
charge from  these  ulcers  might  do  them  harm.  I  should  be  in- 
clined to  regard  these  fistulse  as  marks  of  arrested  development 
of  the  auricle,  since  they  were  congenital  and  not  connected  with 
any  other  form  of  disease  of  this  part. 

They  did  not  communicate  with  the  auditory  canal  or  middle 
ear.  Schwartze '  also  reports  such  cases. 

TUMORS. 

The  tumors  found  in  the  auricle  may  be  divided  into  the 
following  classes  : 

I.  Fibro-cartilaginous. 
II.  Sebaceous. 

III.  Vascular. 

IV.  Malignant. 

FIBRO-CARTILAGINOUS  TUMORS. 

The  first-named  form  is  a  simple  hypertrophy  of  the  normal 
structure  of  the  auricle. 

According  to  Billroth,2  these  tumors  consist  chiefly  of  fusi- 
form cells  and  connective  tissue,  and  are  nothing  more  than 
hypertrophy  of  a  cicatrix  such  as  occurs  on  other  parts  of  the 
body  after  injuries.  They  seem  to  occur  much  more  frequently 
among  the  African  than  the  Caucasian  race.  I  have  removed 
several  of  these  growths  from  the  auricles  of  negro  women, 
while  I  have  but  rarely  seen  them  among  whites.  It  is  not 
true,  however,  that  they  never  occur  in  the  white  race.  I  re- 
moved one  during  the  past  year  from  the  auricle  of  a  German 
woman.  I  am  also  informed  that  they  occur  very  frequently 
among  the  Africans  of  the  East  and  West  Indies,  where  they 
grow  to  an  enormous  size. 

The  etiology  of  these  growths  is  very  simple,  if  my  own  ex- 
perience may  be  trusted  on  this  point.  They  occur  as  the  result 
of  the  irritation  of  the  lobes  produced  by  the  truly  barbarous 

1  Pathological  Anatomy  of  the  Ear.     Translated  by  Orne  Green,  p.  23. 
*  General  Surgical   Pathology   and   Therapeutics,   p.   551.      Translated   by  C.    E 
Haekley,  M.D. 


104  FIBRO-CARTILAGINOUS   TUMORS. 

custom  of  piercing  the  ears  in  order  that  ear-rings  may  be  worn. 
They  are  much  more  apt  to  be  found  in  the  lower  classes,  who 
use  brass  ear-rings,  although  the  growths  may  occur  even  if  gold 
ear-rings  %are  worn.  They  sometimes  reach  an  enormous  size, 
and  become  a  very  serious  deformity.  If  these  ornaments  are 
considered  indispensable,  as  no  doubt  they  are,  ladies  should 
wear  them  by  causing  them  to  be  clasped  around  the  auricle  by 
means  of  a  suitable  contrivance  now  sold  by  the  jewellers  and 
very  much  used. 

One  of  the  older  .authors,  Frank,  gives  illustrations  of  the 
proper  instruments  with  which  to  pierce  the  ears,  with  a  de- 
tailed account  of  the  operation  ;  but  the  efforts  of  the  medical 
adviser  should  be  toward  the  prevention  of  the  custom  rather 
than  increasing  the  facilities  for  retaining  it. 

Dr.  Agnew '  reports  a  case  of  what  finally  came  to  be  a  myxo- 
fibroma  of  the  auricle,  which  arose  from  a  scratch  from  a  toilet- 
pin.  It  occurred  in  a  boy  ten  years  of  age.  At  the  end  of 
eighteen  months  a  tumor  occurred  at  the  site  of  the  injury,  of 
the  size  of  a  buck-shot.  It  returned  almost  immediately,  and  at 
the  end  of  two  years  it  was  again  removed,  and  was  found  to  be 
about  three  times  the  size  of  the  original  growth.  Two  years 
after,  the  tumor  having  returned,  it  was  again  removed.  Dr. 
Agnew  saw  the  boy  when  he  had  reached  the  age  of  eleven,  and 
removed  a  tumor  from  the  place  from  which  these  tumors  had 
been  removed.  Six  months  after  there  was  a  small  nodule  in 
the  lower  end  of  the  scar  near  the  lobule.  Removal  of  this  was 
advised,  but  no  subsequent  history  of  the  case  is  given. 

In  some  cases  it  is  impossible  to  heal  the  edges  of  the  open- 
ing made  for  the  ear-rings,  so  that  there  are  a  few  females  who 
are  never  able  to  wear  them,  on  account  of  the  impossibility 
of  securing  a  sound  cicatricial  border.  I  once  operated  for  the 
closure  of  a  gap  in  the  auricle,  made  by  the  dragging  of  the  ear- 
ring. After  paring  the  edges  and  uniting  them  by  suture,  a 
good  result  was  secured.  Wounds  in  this  region  heal  readily, 
and  with  a  remarkable  absence  of  deformity.  Sutures  are  well 
borne,  and  the  pain  in  healing  is  generally  very  little. 

Fibro-cartilaginous  tumors  should  be  removed  if  they  attain 
such  a  size  as  to  be  at  all  troublesome.  The  removal  is  readily  ef- 
fected by  a  V-shaped  incision  made  with  strong  scissors.  The 
edges  of  the  wound  are  then  brought  together  by  sutures.  The 
resulting  deformity  is  usually  very  slight,  and  is  much  less  than 
that  from  the  tumor. 

Sebaceous  tumors  should  be  removed  by  enucleation. 


1  Transactions  American  Otological  Society,  1876. 


ANGIOMATA   OF  THE  AUKICLE.  105 


ANGIOMATA. 

.  » 

Angioma  of  the  auricle  is  not  a  common  disease.  Cases  have 
been  reported  by  Mussey,1  Kipp,"  Chimani,3  Politzer,4  and  others. 
Chimani,  however,  entitles  his  case  a  cirsoid  aneurism  of  the 
auricle  and  meatus.  Repeated  injections  of  chloride  of  iron 
seemed  to  cure  the  case,  which  was  thus  treated  when  the  pa- 
tient, a  boy,  was  five  years  of  age.  In  four  years  the  disease 
had  returned  so  as  to  be  troublesome.  The  tumor  was  again  in- 
jected with  chloride  of  iron ;  three  injections  at  intervals  of 
some  days  were  made,  when  the  tumor  of  the  auricle  had  near- 
ly disappeared.  That  of  the  canal  was  removed  by  the  knife. 
Kipp's  case  was  the  result  of  a  frost-bite.  After  an  injection  of 
chloride  of  iron  in  the  hands  of  another  surgeon,  the  tumor  in- 
creased in  size.  The  tumor  was  situated  on  the  outer  side  of  the 
left  lobule.  It  was  of  the  size  of  a  hazel-nut.  The  tumor  was 
situated  beneath  the  skin,  which  was  movable  over  it,  and  trav- 
ersed by  numerous  large  veins.  Dr.  Kipp  removed  the  tumor 
with  the  knife.  The  wound  healed  by  first  intention.  It  was 
found  to  be  covered  by  a  fibrous  capsule.  The  tumor  itself  was 
composed  of  spongy  tissue,  similar  to  the  corpus  cavernosum  of 
the  penis.  By  the  microscope  the  growth  was  seen  to  consist 
of  a  network  of  connective  tissue  trabeculse.  The  walls  of  the 
spaces  were  lined  with  a  layer  of  endothelial  cells.  Politzer s 
treated  his  case  by  cauterizing  the  part  of  the  tumor  lying  be- 

•  hind  the  ear  with  Pacquelin's  cautery  (thermo-puncture).    He 
first  tried  subcutaneously  the  largely  dilated  posterior  auricular 
artery.     The  patient  was  dismissed  cured  in  ten  weeks.     The 
auricle  had  decreased  in  size  by  two-thirds  and  no  longer  pul- 
sated. 

When  an  angioma  can  be  readily  separated  from  the  sur- 
rounding tissue,  enucleation  is  to  be  preferred  to  any  other  means 

•  of  removal. 

Dr.  F.  Eve "  reported  a  case  of  aneurism  by  anastomosis  occur- 
ring in  the  auricle,  which  probably  started  from  a  congenital  use- 
void  growth.  The  whole  pinna  above  and  behind  the  meatus  was 
enlarged,  soft,  of  a  dull  red  color  and  pulsating  moderately.  A 
humming  bruit  could  be  heard  on  auscultation.  The  right  com- 

1  American  Journal  of  the  Medical  Sciences,  1853. 

5  Transactions  of  the  American  Otological  Society,  1875,  p.  79. 

3  Transactions  American  Otological  Society,  Blake's  report,  1874. 

4  Text-book,  p.  634.     Translation. 

6  Loc.  cit. 

6  London  Medical  Times  and  Gazette,  May  8,  1880. 


SYPHILIS   OF   THE   AURICLE. 

mon  carotid  and  the  temporal  and  posterior  auricular  arteries 
were  enlarged.  Hemorrhage  had  occurred.  The  whole  auricle 
was  removed  by  Dr.  Thomas  Smith.  There  were  changes  in  the 
tissue  such  as  increase  in  the  number  of  arterioles  and  capillaries, 
hypertrophy  of  the  Malpighian  layer  of  the  cuticle,  and  enlarge- 
ment of  the  sebaceous  glands,  which  were  attributed  to  the  in- 
creased blood-supply.  This  case  is  probably  essentially  of  the 
same  nature  with  those  described  under  the  head  of  "  Angioma." 
Mussey's  case  of  "  aneurismal  tumors  upon  the  ear,"  is  a  re- 
markable one.  There  were  three  tumors.  They  apparently  had 
their  origin  on  a  so-called  ncevus  maternus.  An  alarming  hem- 
orrhage occurred  from  one  of  these  about  a  month  before  Pro- 
fessor Mussey  was  consulted.  They  were  compressible  almost 
to  obliteration,  and  communicated  with  each  other.  The  com- 
mon carotid  on  the  side  of  the  tumor  was  first  tied  ;  in  four 
weeks,  as  the  tumors  were  not  markedly  diminished,  the  caro- 
tid of  the  other  side  was  tied.  A  cure  was  then  obtained.1 


SYPHILIS  OF  THE  AURICLE. 

Bumstead  and  Taylor a  state  that  only  one  case  of  chancre  of 
the  auricle  has  been  reported.  This  was  by  Alb.  Hulot,  in  the 
Ann.  de  Derm,  et  Syph.,  t.  x.,  p.  47.  Paris,  1879.  The  secondary 
manifestations  of  syphilis  are,  however,  occasionally  seen  upon 
the  auricle.  The  various  syphilitic  eruptions  may  occur  here  as 
upon  the  other  parts  of  the  common  integument.  Ulcerative 
processes  from  syphilis  may  take  place  in  the  auricle.  Gummy 
tumors  may  also  occur  in  this  part.  It  is  hardly  necessary  to 
say  anything  more  with  reference  to  these  evidences  of  con- 
stitutional syphilis,  than  that  they  should  be  subjected  to  the 
appropriate  constitutional  treatment  by  means  of  mercury  and 
iodide  of  potassium,  while  soothing  local  applications  are  made. 

HORNY  GROWTHS. 

Buck,3  Burnett,4  and  Pomeroy  5  report  horny  growths  of  the 
auricle.  Their  removal  is,  of  course,  easily  accomplished.  If 
not  thoroughly  done,  the  tumors  will  probably  recur. 

1  American  Journal  of  the  Medical  Sciences,  1853,  vol.  xxvi.,  p.  333. 

8  The  Pathology  and  Treatment  of  Venereal  Diseases.     Fifth  edition,  p.  789. 

8  Transactions  American  Otological  Society,  1870. 

4  Treatise  on  the  Ear,  p.  231. 

8  Treatise  on  the  Ear,  p.  50. 


OTHJEMATOMATA.  107 


OTH^MATOMATA,  OR  VASCULAR  TUMOR  OF  THE  EAR. 

The  peculiar  effusion  of  blood  which  quite  often  occurs  in  the 
auricle,  and  especially  among  the  insane,  and  which  is  known 
as  othsematoma,  hsematoma  auris,  or  vascular  tumor  of  the  au- 
ricle, has  caused  quite  an  amount  of  discussion  among  scientific 
observers.  Virchow '  and  E.  R.  Hun,3  of  Albany,  N.  Y.,  are  the 
authors  who  seem  to  me  to  have  given  us  the  clearest  and  best 
accounts  of  this  interesting  affection,  and,  in  what  I  am  about 
to  say,  I  shall  avail  myself  of  their  labors,  together  with  some 
experience  of  my  own  on  this  subject. 

The  so-called  othsematomata  may  be  divided  into  those  of 
idiopathic  and  traumatic  origin.  The  idiopathic  form  occurs 
chiefly,  though  not  exclusively,  among  the  insane.  I  have  seen 
two  cases  occurring  in  people  of  sound  mind,  which  corre- 
sponded very  well  with  the  descriptions  of  those  occurring  in 
the  insane  as  given  by  Dr.  Hun,  whose  observations  seem  to 
have  been  confined  to  this  class.  Dr.  E.  G.  Loring  has  also 
seen  one  idiopathic  case  in  a  sane  person.  The  symptoms  of 
the  idiopathic  form  of  the  affection  are  as  follows  :  Before  the 
tumor  appears  we  find  the  ear  or  ears,  as  the  case  may  be,  red 
and  swollen,  and  the  face  and  eyes  give  evidence  of  a  strong 
determination  of  blood  ;  occasionally,  however,  there  is  no  red- 
ness of  the  skin,  and  there  is  merely  some  oedema  of  the  auri- 
cle ;  among  the  insane  there  is  no  manifestation  of  general 
•ill-health.  In  a  few  hours,  or  it  may  be  days,  an  effusion  of 
blood  takes  place.  The  tumor  occupies  the  concha  in  the  main, 
but  it  extends  over  the  auricle  so  as  to  obliterate  its  ridges  and 
cause  the  usually  beautiful  part  to  appear  like  a  roundish  red- 
dened tumor,  varying  in  size  from  a  bean  to  a  hen's  egg.  This 
tumor  is  evidently  of  an  inflammatory  nature,  being  hot  and 
painful.  The  swelling  is  usually  quite  firm,  but  a  careful  ex- 
amination will  detect  fluctuation. 

The  vascular  tumor  of  the  auricle,  judging  from  Dr.  Hun's 
statistics,  is  much  more  common  among  men  than  women.  He 
reports  twenty-four  cases,  of  which  twenty-three  occurred  in 
males.  The  form  of  insanity  was  general  paresis  in  eight  cases. 
melancholia  in  six,  acute  mania  in  four,  chronic  mania  in  four, 
and  dementia  in  two.  These  statements  accord  with  the  views 
of  other  authors,  so  that  we  may  conclude  that  hsematoma 
auris,  when  occurring  in  the  insane,  is  a  symptom  which  is 


1  Die  krankhaften  Geschwulsten,  Bd.  I.,  p.  135. 
*  American  Journal  of  Insanity,  July,  1870. 


108 


OTH^EMATOMATA. 


highly  unfavorable,  and  which  points  to  an  incurable  form  of 
disease  of  the  brain. 

The  tumor  either  ruptures  spontaneously,  sometimes  with 
such  violence  as  to  spurt  the  blood  to  a  distance  of  several  feet, 
or,  unless  interfered  with,  is  gradually  absorbed.  Spontaneous 
rupture  is  more  common  than  absorption. 

Dr.  Hun's  observations  show  that  the  traumatic  and  idio- 
pathic  othaematomata  are  not  alike  ;  for  in  one  case  which  he 
details,  an  insane  person,  already  suffering  from  hsematoma  of 
one  auricle,  received  a  blow  from  a  broom-handle  on  the  other, 
which  produced  swelling  and  ecchymosis,  but  no  hcematoma.  We 


FIG.  36. — Othaematoma.  Prom  a  photo- 
graph taken  from  a  plaster  cast,  when  the 
tumefaction  was  greatest  (after  Hun). 


Fia.  37.— The  same  Ear  after  Rup- 
ture and  Contraction  had  taken  place 
(after  Hun). 


must,  therefore,  I  think,  strictly  distinguish  the  idiopathic  from 
the  traumatic  form. 

The  etiology  of  haematoma  is  deemed  by  Hun  to  be  two-fold, 
viz.,  cerebral  congestion  and  centripetal  irritation  of  the  system 
by  the  emotions  ;  and  he  considers  either  of  these  causes  suffi- 
cient to  produce  the  effusion.  In  general  paresis  there  is,  ac- 
cording to  all  authors,  a  tendency  to  repeated  congestions  of  the 
head,  and  it  is  supposed  that  the  blood-vessels  of  the  ears  be- 
come so  dilated  as  to  favor  the  effusion.  The  second  factor  in 
producing  hasmatoma  auris,  centripetal  irritation  of  the  sympa- 
thetic from  strong  emotions,  is  especially  active  among  the 
insane,  because  their  emotions  are  not  under  the  control  of  the 
will. 


OTH^EMATOMATA. 


109 


Virchow  has  made  the  pathology  of  othaematomata  very 
plain,  both  by  his  descriptions  and  the  excellent  illustrations 
which  he  furnishes  in  his  great  treatise  on  tumors.  He  says 
that  ''the  older  authors  described  the  affection  as  erysipelas  of 
the  auricle  occurring  in  the  insane.  It  was  supposed  that  in  the. 
hypersemia  and  general  change  in  the  system  a  hemorrhage 
occurred,  which  caused  a  separation  of  the  perichondrium  from 
the  cartilage  ;  but  in  true  othsematomata,  pieces  of  the  cartilage 
become  attached  to  the  perichondrium." 

CASE  I. — J.  A.  C ,  set.  34.     General  paresis.     Admitted  January,  1857. 

Insanity  hereditary  in  his  family.  Discharged  June,  1858.  Readmitted  May, 
1859.  July  24th,  a  simple  sanguineous  cyst  was  observed  in  each  ear.  Effusion 
rapidly  took  place  until  the  outlines  of  the  auricle  were  obliterated.  Septem- 
ber 30th,  the  tumors  have  gradually  subsided.  Patient  died  May  10,  1860. 


FIG.  38.— Showing  Amount  of  Con- 
traction after  Rupture  of  Cyst  (after 
Hun). 


FIG.  39. — Shows  Separation  of  Perichon- 
drium from  the  Cartilage  (after  Hun).  • 


According  to  the  Berlin  pathologist,  the  morbid  process 
seems  to  be  primarily  a  softening  or  deliquescing  one.  induced 
by  general  disturbances  of  nutrition,  or  possibly — although  this 
class  of  cases  seems  to  belong  to  itself — by  local  injuries  of  the 
cartilage.  The  tumor  disappears  either  by  gradual  absorption, 
spontaneous  rupture,  or  by  the  puncture  of  the  surgeon.  Coag- 
ula  often  form,  which  make  a  delicate  coating  over  the  sepa- 
rated portions,  and  these  afterward  serve  as  means  of  adhesion. 
When  suppuration  does  not  take  place,  great  deformity  is  apt 
to  occur  from  the  thickening  and  retraction  of  the  soft  parts, 
especially  of  the  perichondrium. 


110  OTH^EAIATOMATA. 

CASE  JI. — D.  M ,  sei.  — .  Melancholia.  Second  attack.   Haem'atoma  began 

May  18,  1869.  On  July  3d  had  haematoma  on  both  ears.  August  1st  the  left 
auricle  burst  at  upper  portion  of  concha,  and  the  contents,  consisting  of  fluid 
and  clotted  blood,  were  thrown  to  the  ceiling,  a  distance  of  twelve  feet.  Died 
September  9, 1869.  A  section  of  the  auricles  showed  that  the  perichondrium  was 
much  thickened,  and  separated  from  the  auricular  cartilage  on  its  outer  aspect, 
so  as  to  leave  a  large,  smooth  cavity,  lined  with  a  smooth,  shining  membrane, 
and  containing  a  few  drops  of  serous  fluid. 

Vascular  tumors  caused  by  violence  should  not  be  confound- 
ed with  those  occurring  idiopathically.  Gudden,  a  German 
writer  and  physician  for  the  insane,  quoted  by  Virchow,  has 
shown  that  the  auricles  of  ancient  statues  are  very  frequently 
ornamented  by  tumors  resembling  the  vascular  effusions  seen 
among  the  insane.  In  the  gallery  at  Munich  the  head  of  Hercu- 
les has  such  ears.  These  misshapen  auricles  are  the  typical 
marks  of  the  ancient  boxers  or  pugilists.  Such  fighters  wrapped 
their  hands  in  leather,  and,  thus  armed,  struck  the  ears  of  their 
antagonists ;  consequently  in  the  figures  of  Hercules,  Pollux, 
and  other  classical  fighters,  a  deformed  auricle  is  a  regular  ap- 
pearance. Other  historical  personages — the  Trojan  Hector,  for 
example — are  represented  as  having  othaematomata. 

To  conclude  from  these  observations  that  the  othaematomata 
are  ahuays  the  result  of  traumatic  influences,  that  they  are  more 
frequent  among  the  insane  because  they  are  very  apt  to  injure 
themselves  or  be  injured  by  their  attendants,  seems  to  me  to  be 
manifestly  incorrect,  judging  both  from  Dr.  Hun's  observations 
and  from  the  fact  that  these  tumors  are  very  uncommon.  Even 
the  English  writers,  living  in  the  land  pre-eminent  for  pugilists, 
scarcely  mention  them.  Wilde '  describes  and  gives  an  illustra- 
tion of  one  case,  however,  which  seems  to  have  been  a  haema- 
toma, but  was  not  recognized  as  such  by  the  author.  It  was 
idiopathic  in  origin.  It  occurred  in  a  male  aged  twenty-four, 
and  was  about  the  size  of  a  small  pear.  It  occupied  the  upper 
portion  of  the  left  auricle,  between  the  helix  and  the  concha. 
It  was  treated  by  incisions,  and  considerable  deformity  resulted. 

Toynbee "  describes  these  cases  under  the  head  of  cysts,  and 
seems  inclined  to  ascribe  a  traumatic  origin  to  them,  and  he 
states  that  it  is  the  opinion  of  Dr.  Thurnam,  physician  to  one  of 
the  county  insane  asylums  of  England,  that  they  are  less  fre- 
quent than  formerly,  on  account  of  the  fact  that  violence  is  not 
so  much  employed  in  the  management  of  the  insane.  Dr.  Thur- 
nam evacuated  the  contents  of  the  tumors,  and  used  setons,  and 

1  Aural  Surgery,  English  edition,  p.  164. 

4  Diseases  of  the  Ear,  American  edition,  p.  53. 


OTH^EMATOMATA.  HI 

thus  claims  to  have  prevented  the  deformity  to  some  extent. 
Toynbee  mentions  but  one  case,  that  of  a  boxer,  that  he  has  him- 
self seen  ;  but  his  description  is  not  detailed  enough  to  allow  us 
to  judge  whether  it  was  identical  with  those  observed  in  the  in- 
sane. 

Dr.  Hun  was  so  strongly  of  the  opinion  that  the  idiopathic 
othsematoma  are  symptoms  of  insanity,  that  he  considered  any 
person  having  such  tumor  upon  the  auricle,  even  if  sane,  as 
a  person  to  be  carefully  observed  as  to  cerebral  symptoms. 
This  is  an  opinion  of  Dr.  Hun's  which  I  obtained  in  a  conversa- 
tion with  him  upon  this  subject. 

While  Professor  Brown-Sequard  was  a  resident  of  New  York, 
I  had  an  interesting  and  instructive  interview  with  him  on  the 
subject  of  vascular  tumors  of  the  auricle.  Dr.  Sequa"rd  has 
found  that  sections  of  the  restiform  bodies,  or  largest  column 
of  the  medulla  oblongata,  in  animals  (Guinea-pigs)  will  produce 
a  hemorrhage  beneath  the  skin  of  the  auricle  in  from  twelve  to 
twenty-four  hours.  This  hemorrhage  is  soon  followed  by  gan- 
grene of  the  part.  I  had,  through  Dr.  Sequard's  courtesy,  the 
opportunity  of  examining  such  ears,  and  of  verifying  the  fact  of 
the  subsequent  gangrene.  The  hemorrhage  usually  occurs  in 
the  fossa  navicularis  of  the  auricle.  This  hemorrhage  usually 
takes  place  on  the  same  side  with  that  of  the  section. 

Dr.  Sequard  also  stated  that  sections  of  the  sciatic  nerve,  by 
reflex  action  upon  the  medulla,  would  produce  the  same  result, 
and  that  he  had  produced  in  his  own  person  flushing  of  the  auri- 
cle by  pinching  the  sciatic  nerve.  Dr.  Sequard  believes  that  dis- 
ease of  the  base  of  the  brain,  which  is,  however,  not  always 
attended  by  insanity,  is  the  cause  of  hsematoma  auris.  In  the 
human  animal,  gangrene  is  not  apt  to  result  from  the  hemor- 
rhage ;  probably  because  the  thicker  tissue  of  the  human  auricle 
has  a  greater  resisting  power. 

It  will  thus  be  seen  that  Dr.  Sequard's  views  confirm  those  of 
Dr.  Hun,  while  they  shed  a  new  light  upon  the  clinical  observa- 
tions of  the  latter. 

Meyer '  and  Blake 2  report  cases  of  othsematomata  in  which 
pressure  and  massage  were  employed  in  treatment  with  good  re- 
sults. Both  of  Blake's  cases  were  males,  with  no  trace  of  other 
physical  disease,  of  sound  minds,  and  with  "  no  antecedent  or 
individual  history  of  insanity  or  intemperance."  The  first  case, 
however,  occurred  in  a  pedestrian,  being  the  "  champion  short- 
distance  walker."  As  Dr.  Blake  suggests,  this  occupation,  from 

1  Archiv  fur  Ohrenheilkunde,  vol.  xvii.,  p.  2. 

2  American  Journal  of  Otology,  vol.  iii.,  p.  193. 


112  OTH^EMATOMATA. 

its  severe  strain  upon  the  muscles  and  the  circulation,  may  have 
had  some  bearing  upon  the  etiology.  This  patient  flushed  easily 
under  any  physical  exertion  or  slight  mental  excitement.  The 
tumor  was  opened,  two  drachms  or  more  of  bloody  serum  and  a. 
little  dark  blood  withdrawn,  the  cavity  was  then  well  probed, 
and  sponge  pads  were  adjusted  to  the  anterior  and  posterior 
surfaces  of  the  auricle  and  kept  in  place  by  an  elastic  flannel 
bandage.  This  treatment  was  continued  for  a  week,  and  then 
massage  was  employed  four  times  at  the  interval  of  several 
days  for  about  fifteen  minutes  at  each  visit  by  an  expert,  Dr. 
Graham,  of  Boston.  "The  tissues  were  gently  and  firmly  rolled 
between  the  thumb  and  finger  with  gradually  increasing  force 
until  the  last  five  minutes,  when  the  pressure  was  gradually  dk 
minished."  Under  this  treatment  the  ear  resumed  its  normal 
appearance  in  about  two  months. 

In  the  second  case,  that  of  a  teamster,  the  hemorrhage  oc- 
curred the  day  after  the  patient  had  exerted  himself  very  much 
in  loading  heavy  bales  of  goods.  He  was  a  temperate  man,  but 
undersized,  and  was  occasionally  subject  to  very  severe  exertion 
in  his  business.  He  was  seen  by  Dr.  Blake  on  the  very  day  the 
hemorrhage  occurred.  The  same  treatment  was  applied  as  in  the 
previous  case,  and  on  the  fifth  day  the  auricle  had  nearly  re- 
sumed its  normal  appearance,  and  the  patient  was  discharged. 
Meyer's  cases  did  not  do  quite  as  well  as  these.  Blake  thinks  it 
possible  that  the  stuffing  of  the  cavity  with  picked  lint  and  too 
frequent  massage — four  times  daily,  as  practised  by  Meyer — may 
have  prevented  the  best  results. 

The  result  in  three  of  Meyer's  cases  was  very  satisfactory ;. 
in  two  of  them  resorption  took  place  within  a  few  weeks,  and 
there  was  finally  no  deformity  of  the  auricle.  It  is  interesting 
to  note  that  one  parent  in  each  of  Meyer's  cases  had  been  insane. 
In  view  of  this,  Meyer  calls  attention  to  Hun's  observation,  that 
the  appearance  of  othsematoma  in  sane  persons  usually  precedes, 
a  later  mental  disturbance,  and  agrees  with  my  own  opinion, 
that  while  all  those  suffering  from  this  vascular  tumor  of  the 
auricle  may  not  be  insane,  yet  they  probably  have  some  kind  of 
disease  of  the  brain.  These  observations  seem  to  be  borne  out 
by  Brown-Sequard's  experiments,  and  by  an  analysis  of  the  cases, 
of  Blake  and  Meyer.  Othsematomata  do  not  seem  to  occur  in 
persons  entirely  free  from  cerebral  disease. 

From  all  that  has  been  written  of  vascular  tumors  of  the 
ear,  and  from  my  own  experience,  I  think  we  may  safely  af- 
firm— 

First.-t-That  there  are  two  distinct  varieties  of  othsemat^-. 
mata  :  Traumatic  and  Idiopathic. 


PERICHONDRITIS   OF  THE  AURICLE. 


113 


Second. — That  the  idiopathic  is  much  more  common  among 
the  insane  than  among  others,  but  that  identically  or  nearly  the 
same  affection  does  occur  among  the  sane.  It  is  probable,  how- 
ever, from  Brown-Sequard's  experiments,  that  the  affection  is 
caused  by  some  lesion  of  the  base  of  the  brain,  so  that  although 
persons  suffering  from  vascular  tumor  of  the  ear  may  not  always 
be  insane,  they  generally  have  brain  disease,  or  they  may  be- 
long to  the  large  class  of  neurotic  or  neurasthenic  people. 

Third. — The  traumatic  form  differs  from  the  idiopathic  in  be- 
ing a  simple  extravasation  of  blood  from  vessels  ruptured  by 
violence.  In  such  cases  the  deformity  resulting  from  the  spon- 
taneous effusions  does  not  occur,  unless  among  professional 
pugilists,  where  the  violence  is  frequently  repeated,  and  the  auri- 
cle, from  repeated  hemorrhages, 
assumes  a  shape  like  that  result- 
ing from  a  true  othsematoma. 

Fourth.  —  The  treatment  by 
pressure  after  evacuation  of  the 
contents,  followed  by  moderate 
massage,  seems  to  give  very  good 
results  and  may  be  confidently 
practised. 

PERICHONDRITIS  AND  CHONDRITIS. 

Any  inflammation  of  the  in- 
tegument, connective  tissue,  and 
cartilage  of  the  auricle,  leading  to 
effusion  of  serum,  blood,  or  the 
formation  of  pus,  will  be  apt  to 
cause  a  deformity  of  the  part ;  but 
such  a  case  should  be  distinguished 
from  an  othaematoma. 

The  sketch  from  a  photograph, 
which  is  here  given,  shows  the 
result  of  what  was  at  first  an  in- 
flammation of  the  cartilaginous 

portion  of  the  auditory  canal.  A  polypus  formed  from  the  pro- 
longed use  of  poultices  for  the  relief  of  what  was  supposed  to 
be  a  furuncle,  the  inflammation  extended  to  the  tissue  of  the 
auricle,  and  after  a  long  period  of  suffering,  during  which  small 
abscesses  were  formed,  which  were  evacuated  after  pursuing  a 
sinuous  course  in  the  integument,  the  auricle  attained  the  shape 
which  is  here  shown.  The  hearing  power  is  unimpaired  when 
the  very  small  meatus  is  kept  open. 

Several  cases  of  inflammation  of  the  tissues  of  the  auricle 


FIG.  40. — Auricle  Deformed  by  Inflam- 
mation (chondritis). 


114  PERICHONDEITIS   OF  THE   AURICLE. 

have  been  published  since  my  case  was  reported  in  1873, '  and 
some  of  the  reporters  have  fallen  into  the  natural  error  of  stating 
that  similar  cases  have  not  been  before  noticed.  All  these  cases, 
although  differing  in  minor  respects,  agree  in  being  essentially 
inflammations  of  the  perichondrium,  and  in  leaving  some  de- 
formity behind  them  as  a  rule.  I  did  not  name  my  case  perichon- 
dritis,  when  it  was  first  reported,  but  a  comparison  of  the  account 
of  the  case  with  those  of  later  writers  will  show,  I  believe,  that 
the  various  reporters  are  speaking  of  the  same  form  of  disease. 
Chimani  was  one  of  the  first,  if  not  the  first,  to  report  a  case  of 
perichondritis  a  of  the  auricle.  His  was  that  of  a  soldier  in  the 
Austrian  army,  who  was  suddenly  seized  with  a  sensation  of 
heat  and  pain  in  the  left  auricle,  with  swelling  of  its  concave  sur- 
face. Four  days  after  the  attack,  when  he  entered  the  hospital, 
the  whole  auricle  was  a  shapeless  mass  of  inflammation.  Poul- 
tices were  applied,  and  in  three  days  fluctuation  appeared.  An  in- 
cision was  made ;  quite  a  quantity  of  synovial-like  fluid  mingled 
with  pus  was  evacuated.  It  was  afterward  treated  as  an  abscess 
and  dressed  with  picked  lint  and  a  bandage.  In  two  weeks  after 
the  patient  came  under  Chimani's  care,  the  auricle  had  recovered 
its  normal  form  and  elasticity.  Chimani  considers  this  case  as  a 
primary  one  of  the  perichondrium — "  an  inflammation  with  the 
formation  of  exudation."  The  absence  of  a  bluish-red  coloring 
and  the  character  of  the  contents  distinguish  it  from  a  vascular 
tumor.  Dr.  Pomeroy's '  case  of  abscess  of  the  auricle  was  one  in 
which  the  disease  extended  from  the  tympanic  cavity  to  the 
canal  and  thus  to  the  auricle.  The  patient  was  a  man  forty-two 
years  of  age.  The  auricle  did  not  become  involved  for  some 
weeks  after  the  primary  inflammation.  The  patient  was  not 
under  constant  observation,  and  recovery  took  place  after  free 
evacuation  of  the  pus,  with  great  deformity.  This  case  is  to  be 
classed  with  those  of  secondary  inflammation  of  the  auricle,  such 
as  that  reported  by  myself.  It  may  be  said  here,  that  it  is  not 
unusual  to  see  very  considerable  swelling  of  the  cartilaginous 
part  of  the  canal  following  an  inflammation  of  the  tympanic  cav- 
ity. This  usually  subsides  under  the  use  of  the  warm  douche, 
and  generally  without  extending  to  the  auricle.  Knapp  *  re- 
ports three  cases.  The  first  began  as  an  inflammation  of  the 
canal,  and  after  some  weeks  recovered  also  with  deformity. 
The  second  case  was  seen  but  once,  and  no  details  are  given 
except  that  there  was  fluctuation  in  the  concha.  Tie  third  case 

1  Transactions  of  American  Otological  Society. 
'Archiv  fur  Ohrenheilkunde,  Vol.  II.,  p.  171. 

3  Transactions  of  the  American  Otological  Society.  Vol.  II.,  p.  83. 

4  Archives  of  Otology,  Vol.  IX.,  p.  196. 


PERICIIONDEITIS   OF   THE  AUEICLE.  115 

was  one  shown  Dr.  Knapp  by  his  colleague,  Dr.  Brandeis.  Dr. 
Brandeis'  patient  had  a  "mild  chronic  aural  catarrh."  There 
was  a  reddish  diffuse  swelling  of  the  cartilage  of  the  meatus  and 
the  adjacent  parts  of  the  concha.  After  an  incision  watery  pus 
escaped,  and  the  swelling  disappeared  in  a  few  weeks. 

Pooley's  case  '  occurred  in  a  woman  of  twenty-one.  When 
she  came  under  Dr.  Pooley's  care,  there  was  the  history  of  a  boil 
in  the  ear  ;  the  swelling  extended  from  the  canal  to  the  concha, 
and  finally  to  the  entire  anterior  surface  of  the  concha.  It  was 
treated  by  incisions,  injections  of  a  weak  solution  of  carbolic  acid 
and  iodine.  Pressure  was  also  employed  by  means  of  a  bandage. 
The  pressure  seemed  to  alleviate  the  pain.  Considerable  deform- 
ity of  the  concha  remained.  The  acute  inflammatory  symptoms 
lasted  for  about  two  months,  and,  as  in  all  these  cases,  the  long- 
continued  suffering,  the  discharge  undermined  the  general 
health.  Pooley  does  not  regard  frequent  incisions  as  assisting 
very  much,  but  as  perhaps  aggravating  the  case. 

The  lobule  may  be  affected  in  perichondritis  and  may  not. 
The  cases  reported  do  not  differ  in  character,  but  simply  in  in- 
tensity and  course.  Dr.  Knapp's  case,  like  mine,  arose  from  a 
f uruncular  inflammation,  and  after  this  suppuration  of  the  drum- 
head occurred.  This  is  an  unusual  order  of  things.  Whether  or 
not  the  lobule  is  affected  certainly  depends  upon  other  causes 
than  the  existence  of  a  perichondritis.  In  my  case  there  was 
perichondritis  and  also  a  slight  affection  of  the  lobule. 

These  cases,  except  that  of  Chimani,  are  essentially  the  same 
with  that  reported  by  me  in  full  in  1873. 2  As  I  then  said,  the 
extension  of  the  inflammation  of  the  auditory  canal  to  the  car- 
tilage and  perichondrium  of  the  auricle  is  unusual.  I  believe 
with  Pooley,  that  incisions  may  be  too  frequently  made,  and 
that  they  are  rather  to  be  avoided  than  employed,  although  not 
entirely  given  up. 

Kipp3  also  reports,  under  the  head  of  "Spurious  Othsema- 
toma  of  Both  Ears  the  Result  of  a  Burn,"  a  case  of  perichon- 
dritis of  the  auricle.  In  his  case  there  was  scarcely  any  de- 
formity, simply  a  wrinkled  condition  of  the  fossa  of  the  helix. 
After  incision  Kipp  employed  tincture  of  iodine  to  the  outer  and 
inner  surface  of  the  swellings. 

It  will  be  seen  that  Chimani's  case  is  the  only  one  of  those 
here  reported,  that  bears  any  close  resemblance,  in  its  origin  or 
course,  to  the  othaematomata.  The  others  are  clearly  like  the 


1  Medical  Record,  1881. 

2  Transactions  American  Otological  Society.     Boston,  1873. 

3  Ibid.,  1873. 


116  MALIGNANT  DISEASE   OF   THE   AURICLE. 

cases  of  Dr.  Pomeroy  and  myself,  and  belong  to  those  of  second- 
ary inflammations.  While  this  form  of  disease,  as  has  been  said, 
is  rare,  the  primary  form  is  much  rarer. 

Chondritis  and  perichondritis  of  the  auricle  may  result  by 
simple  extension  of  an  inflammation  of  the  cartilage  of  the 
canal.  It  is  probable  that  prolonged  poulticing  may  favor  such 
an  extension.  The  deformity  from  such  an  inflammation  will 
be  considerable,  under  the  most  favorable  circumstances,  if  the 
inflammation  once  set  in.  When  fluctuation  occurs,  it  is  better 
to  make  a  thorough  opening,  and  to  connect  sinuses  by  cutting 
so  as  to  convert  them  into  open  wounds.  Gruening  recommends 
cutting  through  the  entire  auricle,  from  before  backward  ;  while 
it  is  of  the  utmost  importance  to  secure  thorough  drainage,  I 
do  not  think  incisions  entirely  through  the  tissues  necessary 
for  this.  lodoform  gauze  forms  a  good  dressing  after  incisions. 
Vaseline  is  a  good  application  for  the  swelled  tissue  when  sup- 
puration does  not  occur.  Over  this,  cotton  wool  and  a  bandage 
generally  form  a  comfortable  dressing,  and  perhaps  aid  in  les- 
sening the  inevitable  deformity.  I  have  seen  several  of  these 
tedious  and  trying  cases  since  the  last  edition  of  this  book  was 
issued,  and  see  no  reason  to  doubt  my  original  opinion  that  they 
usually  -originate  in  the  cartilage  of  the  canal,  and  that  any  case 
of  furuncle  under  unfavorable  conditions,  or  perhaps  injudicious 
treatment,  may  result  in  chondritis  or  perichondritis  of  the 
auricle.  Perichondritis  and  chondritis  may  be  readily  distin- 
guished from  othsematoma,  if  the  disease  be  seen  early  in  its 
course,  but  when  the  canal,  if  once  diseased,  has  recovered,  and 
the  auricle  alone  remains  affected,  there  may  be  a  possibility  of 
error. 

MALIGNANT  DISEASE. 

Epithelioma. — The  auricle  is  sometimes,  although  not  fre- 
quently, the  seat  of  malignant  disease.  I  have  observed  one 
case  of  epithelioma  of  this  part,  in  which  the  whole  auricle  was 
destroyed,  and  the  disease  had  invaded  the  auditory  canal.  I 
lost  sight  of  the  patient  after  some  weeks,  and  I  can  give  no  ac- 
count of  the  subsequent  course  of  the  disease,  which  was  un- 
checked by  the  treatment  adopted — the  application  of  fuming 
nitric  acid.  Dr.  J.  Orne  Green,  of  Boston, '  also  reports  a  case, 
and  quotes  one  from  Velpeau. 

Epithelioma  of  the  auricle  usually  begins  as  a  small  papule, 
which  finally  develops  into  an  open  ulcer.  This  spreads  very 


Transactions  American  Otological  Society,  third  year. 


ECZEMA   OF   THE  AUEICLE.  117 

rapidly,  involving  finally  the  auditory  canal,  and,  unless  ar- 
rested, the  deeper  parts.  Excision  or  amputation  of  the  parts  is 
the  only  proper  treatment.  When  the  auricle  alone  is  involved, 
this  is  very  easily  accomplished.  In  the  healing  process  care 
should  be  taken,  as  suggested  by  Dr.  Green,  to  prevent  the 
closure  of  the  meatus  by  the  cicatrix,  a  result  which  followed  in 
the  case  reported  by  him,  in  consequence  of  the  refusal  of  the 
patient  to  remain  under  observation  until  the  wound  was  healed. 

Sarcoma. — Sarcomatous  tumors  may  occur  on  the  auricle  as 
well  as  in  the  auditory  canal,  where  they  arise  from  the  carti- 
laginous portion.  They  grow  very  slowly,  but  they  may  extend 
to  the  auditory  canal,  to  the  middle  ear,  and  even  to  the  laby- 
rinth and  meninges  of  the  brain.  Early  removal  is  the  only 
safe  means  of  treatment,  and  even  then  the  growth  may  return. 

The  accompanying  engraving  is  a  representation  of  a  tumor 


FlG.  41. — Tumor  of  the  Anterior  Part  of  Auricle  and  Auditory  Canal. 

of  the  auricle,  apparently  beginning  in  the  parotid  gland,  which 
was  seen  at  my  clinic  in  1883.  The  patient  was  a  woman  of 
about  forty-five  years  of  age,  otherwise  healthy. 


ECZEMA. 


Eczema  of  the  auricle  is  not  one  of  the  most  frequent  affec- 
tions of  the  ear,  as  shown  by  the  statistics  of  eye  and  ear  hospi- 
tals and  writers  on  otology ;  but  a  large  number  of  cases  never 
come  under  the  attention  of  special  observers,  and  are.  conse- 
quently, not  found  in  their  statistics.  Inasmuch  as  eczema  of 


118  ECZEMA    OF    THE   AURICLE. 

the  auricle  is  usually  attended  by  the  same  disease  in  the  audi- 
tory canal,  it  will  be  more  convenient  to  speak  of  them  both  at 
this  time. 

Eczema  of  the  ear,  seems  to  occur  more  frequently  among 
females  than  males,  but  it  is  found  in  both  sexes.  The  symp- 
toms are  the  same  as  those  of  eczema  in  other  parts  of  the  body, 
with  some  symptoms  peculiar  to  the  ear.  The  symptoms  pecu- 
liar to  the  ear  are  redness,  swelling,  and  the  formation  of  ves- 
icles which  become  pustular,  and  which  finally  cover  the  whole 
region  with  unsightly  crusts,  from  which  a  discharge  occurs. 
The  auricle  becomes  a  misshapen  mass,  while  the  swelling  and 
incrustation  of  the  integument  lining  the  auditory  passage  and 
membrana  tympani  impair  the  hearing  to  a  serious  extent. 
Fulness  and  noise  in  the  ears  are  then  added  to  the  patient's 
other  symptoms,  and  the  condition  is  unpleasant  in  the  highest 
degree.  The  disease,  when  left  to  itself,  is  apt  to  have  a  very 
chronic  course,  and  yet  it  is  very  amenable  to  proper  treatment. 
The  causes  of  eczema  are  not  very  clear.  I  have  usually  ob- 
served it  in  persons  of  weak  constitutions,  and  not  among  the 
strong  and  vigorous.  It  rarely  occurs  upon  the  auricle  alone;  but 
it  is  usually  found  in  conjunction  with  the  same  disease  on  other 
parts  of  the  body,  most  frequently  in  conjunction  with  eczema 
of  the  face  and  head,  although  it  sometimes  occurs  on  the  auri- 
cle and  in  the  meatus  alone. 

According  to  Ausspitz,1  formerly  an  assistant  to  Hebra,  ecze- 
ma of  the  ear  differs  from  the  same  disease  as  it  appears  in 
other  parts  of  the  body,  in  occurring  with  a  greater  amount  of 
swelling  and  secretion  of  more  serous  fluid  than  is  usual,  together 
with  the  more  frequent  appearance  of  fissures  in  the  tissue. 

Treatment. — The  results  of  treatment  of  acute  eczema  are 
usually  soon  seen.  The  advice  of  Ausspitz,  to  do  as  little  as 
possible  in  the  acute  form,  is  excellent.  The  auricle  should  be 
kept  from  the  air.  This  may  be  accomplished  by  the  use  of  oils, 
powders,  or  even  by  a  plaster-of -Paris  bandage.  A  good  appli- 
cation is  the  formula  of  Ausspitz  : 

B .    Flor.  Zinci 3  ij. 

Pulv.  Alum,- 

Amyli  Pulv aa   §  j. 

M.   Ft.  pulv. 

This  powder  is  dusted  over  the  affected  portion  with  a  camel's- 
hair  brush.  If  the  auricle  be  excoriated  and  sensitive,  astringent 

1  Archir.  fur  Ohrenheilkunde,  Bd.  I.,  p.  124. 


ECZEMA   OF  THE   AURICLE.  119 

solutions  of  sulphate  of  zinc  may  be  used.  I  usually  employ 
vaseline  or  cold  cream  in  the  early  stages  of  eczema  of  the  auri- 
cle. Cod-liver  oil  is  also  a  good  application.  I  endeavor  to  keep 
the  parts  constantly  covered  with  such  a  non-stimulating  oint- 
ment as  one  of  those  just  named. 

At  the  same  time  with  this  local  treatment,  the  physician 
should  carefully  consider  the  general  state  of  the  patient,  since 
in  this  a  cause  for  the  eczema  may  often  be  found,  which  being 
removed  by  appropriate  management,  will  prevent  a  relapse  of 
the  affection. 

Eczema  of  the  auricle  and  auditory  canal  is  not  often  brought 
to  the  notice  of  the  surgeon  until  it  has  become  chronic.  Its 
treatment  then  may  require  the  greatest  patience  and  care.  The 
treatment  which  I  have  found  usually  successful  is  the  following : 
The  auricle  is  carefully,  but  liberally,  anointed  with  a  one  per 
cent,  solution  of  carbolized  oil.  The  auricle  is  then  covered  with 
an  impermeable  sheeting  of  rubber  tissue-paper  or  oiled  silk,  in 
order  to  keep  the  parts  soft  and  pliable,  and  bandaged  accord- 
ingly. An  improvement  will  soon  be  noticeable,  inasmuch  as  the 
crusts  will  become  detached.  The  inflamed  corium  which  is  now 
exposed  will  soon  yield  to  a  soothing  salve. 

The  diachylon  ointment  of  Hebra,  spread  thickly  on  lint  and 
applied  to  the  surface  will  act  very  well.  After  the  eczema  has 
ceased  to  exude,  we  may  conveniently  add  the  oil  of  tur  ol.  fagi, 
or  ol.  cadini — one  drachm  to  the  ounce,  either  to  Hebra's  oint- 
ment or  to  the  officinal  zinc  salve,  to  which  a  little  oil  of  sweet 
almonds  may  be  mixed.  An  addition  of  salicylic  acid  in  non- 
irritating  doses,  i.e.,  three  grams  to  the  ounce  of  salve,  will  pro- 
mote the  formation  of  healthy  epidermis. 

The  local  treatment  of  the  auditory  canal  is  often  unsuccess- 
ful from  the  want  of  the  personal  attention  of  the  physician.  No 
one  who  is  unable  to  examine  the  external  opening  of  the  ear 
down  to  the  membrana  tympani,  can  tell  when  it  is  or  is  not 
clean.  Without  a  thorough  removal  of  the  material  thrown  off 
in  an  eczema  there  can  be  no  cure.  An  eczematous  auricle  may 
perhaps  recover  spontaneously,  an  eczematous  auditory  canal 
will,  probably,  never  thus  return  to  a  normal  condition.  The 
material  thrown  off  from  the  inflamed  integument  collects  in 
the  narrow  passage,  and  by  mechanical  irritation  increases  the 
swelling,  and  produces  the  most  troublesome  symptom  of  the 
disease — impairment  of  hearing.  The  auditory  canal  should  be 
therefore  carefully  cleansed  every  day  with  the  syringe  and 
angular  forceps  or  cotton-holder,  under  a  good  illumination  with 
the  otoscope,  and  then  an  appropriate  liquid  application  be 
made.  A  liquid  preparation  is  to  be  preferred  to  an  unctuous 


120  ERYSIPELAS    OF  THE   AURICLE. 

one,  for  the  simple  reason  that  an  ointment  will  again  block  up 
the  passage,  and  thus  prevent  the  patient  from  securing  the  full 
benefit  to  his  hearing  power  which  the  removal  of  the  epidermis, 
crusts,  and  pus  has  produced.  We  may  fail  to  cure  many  a 
case  of  disease  of  the  integument  lining  this  part,  if  we  do  not 
carry  out  our  own  advice  ;  we  should  never  give  over  the  treat- 
ment into  the  hands  of  the  parents  or  attendants  of  the  patient, 
for  they  will  be  incompetent  assistants. 

The  warm  douche  is  very  valuable  in  the  treatment  of  chronic 
eczema  of  the  canal.  It  allays  itching  sensations,  and  is  usually 
very  grateful  to  the  patient.  The  use  of  the  douche  may  be  en- 
trusted to  the  patient  himself.  It  is  well  to  use  it  very  often  in 
the  early  periods  of  treatment,  say  once  an  hour.  The  warm 
water  is  a  direct  antiphlogistic  :  I  have  seen  obstinate  cases  of 
inflammation  of  the  canal,  that  have  existed  for  years,  cured  by 
its  use  alone. 

The  application  of  nitrate  of  silver  in  solutions  of  from  ten  to 
forty  grains  to  the  ounce,  is,  I  believe,  on  the  whole,  the  best 
that  can.  be  made  in  the  treatment  of  eczema  of  the  canal.  The 
disease  may  be  often  complicated  with  aspergillus,  or  a  vege- 
table fungous  growth  in  the  canal.  Diachylon  ointment  on  a 
little  cotton,  forms  a  good  application  to  keep  apart  the  walls  of 
the  canal  at  the  meatus. 

Bichloride  of  mercury  in  solutions  of  from  one-twelfth  to  one- 
fourth  of  a  grain  to  the  ounce,  applied  with  a  dropper  or  by 
means  of  the  cotton-holder,  has  proved  an  efficient  remedy  in 
my  hands  in  chronic  eczema  of  the  canal. 

The  only  specific  remedy  for  internal  use  in  chronic  eczema 
of  the  auricle,  as  well  as  that  of  the  same  disease  in  other  parts 
of  the  body,  is  arsenic.  In  chronic  cases  I  usually  give  Fowler's 
solution  in  connection  with  the  local  treatment,  and  it  is  gener- 
ally of  great  avail. 

There  are  various  arsenical  waters  that  are  of  service  in  the 
treatment  of  chronic  eczema  in  the  ear,  as  well  as  that  affecting 
other  parts  of  the  body.  One  that  I  have  used  with  apparent 
benefit  is  from  the  Virginia  Springs. 

ERYSIPELAS. 

Facial  erysipelas  often  begins  at  the  auricle,  and  sometimes 
it  is  limited  to  this  part.  It  sometimes  also  occurs  in  the  course 
of  chronic  eczema.  Indeed,  erysipelas  occasionally  has  its  ori- 
gin in  a  small  eczematous  patch  or  spot  near  the  auricle.  It  is 
probable,  however,  that  this  never  occurs  if  the  subject  be  in 
good  general  condition.  The  local  treatment  that  I  have  em- 
ployed with  satisfaction,  is  an  application  of  a  solution  of  acetate 


EFFECTS    OF    GOUT — INJURIES.  121 

of  lead,  in  tincture  of  opium  and  water,  the  famous  lead-and- 
opium  wash.  It  is  important,  especially  in  delicate  subjects, 
that  eczematous  spots  behind  the  ear  be  promptly  treated,  lest 
they  become  the  starting-point  of  erysipelas.  Oxide  of  zinc  oint- 
ment is  a  good  application  for  small  eczematous  ulcers. 

THE  EFFECTS  OF  GOUT. 

Calcareous  formations  are  often  found  in  the  auricle,  in  per- 
sons of  a  gouty  habit,  as  in  other  parts  of  the  body.  These 
symptoms  of  gout  are  often  accompanied  by  a  great  deal  of  local 
pain,  which  is  sometimes  relieved  by  an  unctuous  application  to 
the  hardened  and  tender  parts.  Dr.  Garrod,1  of  London,  first 
called  attention  to  these  formations,  which  he  found  to  be  urate 
of  soda.  They  were  most  frequently  found  by  Garrod  on  the 
upper  border  of  the  helix,  and  were  supposed  not  to  exist  on  the 
lower  part  of  the  auricle  ;  but  I  saw  what  seemed  to  be  such  a 
formation,  in  the  concha  of  a  gentleman  who  suffered  from 
gout.  Unlike  those  cases  reported  by  Dr.  Garrod,  this  spot  was 
very  painful. 

Where  the  gouty  diathesis  exists,  it  is  not  uncommon  to  find 
heat  and  pain  in  the  cartilage  of  the  auricle.  The  practitioner 
should  be  on  the  lookout  for  such  cases  of  apparently  simple 
dermatitis,  for  they  may  indicate  the  constitutional  trouble, 
which  will  only  be  relieved  by  treatment  of  the  general  system. 

INJURIES  OF  THE  AURICLE. 

Wounds  of  the  auricle  may  sometimes  be  followed  by  an  ery- 
sipelatous  inflammation,  but  this  is  not  apt  to  be  the  case. 

They  usually  heal  promptly,  without  suppuration,  although 
inflammation  of  the  cartilage  or  the  perichondrium  may  result. 
Injuries  of  the  auricle  from  direct  violence,  such  as  pugilists  in- 
flict upon  each  other,  generally  produce  great  deformity.  The 
treatment  of  such  injuries  requires  no  especial  notice  in  a  work 
of  this  kind. 

ANGIOMA. 

At  the  February  meeting  (1884)  of  the  New  York  Ophthalmo- 
logical  Society,  Dr.  E.  Gruening  reported  an  interesting  case  of 
angioma,  of  which  he  has  been  kind  enough  to  furnish  me  an 
account  for  these  pages. 

In  October,  1883,  a  man,  aged  twenty-three,  consulted  Dr.  Omening  on  account 
of  a  circumscribed  swelling  in  his  right  ear.  He  stated  that  he  had  first  noticed 

1  Troltsch :  Diseases  of  the  Ear,  p.  56. 


122  ERYSIPELAS   OF  THE  AUHICLE. 

a  little  growth  two  years  before.  He  had  never  suffered  from  any  injury  of  the 
ear.  No  congenital  anomaly  had  been  observed.  He  consulted  Dr.  Gruening 
about  the  tumor  because  its  pulsating  sounds  had  become  very  annoying,  espe- 
cially in  the  stillness  of  the  night.  There  was  found  a  semi-globular,  bluish, 
soft,  and  strongly  pulsating  tumor  occupying  the  right  concha  and  encroaching 
somewhat  upon  the  lower  wall  of  the  external  auditory  canal.  The  tumor  had  a 
diameter  of  fifteen  millimetres  at  its  base,  and  an  elevation  of  nine  millimetres 
above  the  surrounding  skin.  Pressure  with  the  fingers  easily  emptied  the  tumor, 
but  the  pulsation  was  not  diminished  by  pressure  upon  the  arteries  of  the  head 
and  neck.  The  whole  mass  was  excised  on  October  25th.  The  incision  was 
carried  through  sound  skin  and  the  underlying  cartilage  was  removed  with  it. 
The  copious  hemorrhage,  venous  from  the  centre  and  arterial  from  the  edges, 
was  arrested  by  pressure.  The  wound  healed  slowly  by  succulent  granulations. 
Four  weeks  later  a  soft  pulsating  cicatrix  had  formed. 

Dr.  Gruening's  case  is  an  essential  contribution  to  our  knowl- 
edge of  this  rare  affection.  If  the  pulsating  cicatrix  enlarges  or 
is  troublesome  to  the  patient,  it  will  be  proper  to  excise  it. 


CHAPTER  V. 

DIFFUSE  AND  CIBCUMSCBIBED  INFLAMMATION  OF  THE  EXTER- 
NAL AUDITOEY  CANAL. 

Comparative  Frequency  of  these  Affections. — Diffuse  Inflammation. — Leeches. — In- 
cisions.— Warm  Douche. —Fountain  Syringe. — Fayette  Taylor's  Douche. — Method 
of  Syringing.  — Syringes.  — Anodynes.  — Desquamati ve  Inflammation.  — Furuncles. 
— Local  and  Constitutional  Treatment. — Calcium  Sulphide. — Lowenburg's  Views. 

THE  affections  of  the  external  auditory  canal  may  be  conven- 
iently arranged  as  follows  : 

I.  Diffuse  inflammation. 
II.  Circumscribed  inflammation. 

III.  Vegetable  fungous  growths. 

IV.  Inspissated  cerumen. 
V.  Eczema. 

VI.  Foreign  bodies. 
VII.  Polypi. 

VIII.  Exostoses  and  hyperostoses. 
IX.  Narrowing  and  closure  of  the  canal. 

X.  Syphilitic  condylomata  and  ulcers. 

To  avoid  any  misconception,  I  would  remark  that  while 
bony  growths  (exostoses  and  hyperostoses)  are  classed  under 
the  affections  of  the  external  auditory  canal,  they  are  generally 
consequences  of  inflammations  of  the  middle  ear.  It  will  there- 
fore be  more  appropriate  to  consider  this  rather  important  sub- 
ject under  the  head  of  diseases  of  that  part.  An  account  of 
their  pathology  and  treatment  will  be  found  in  the  chapter  de- 
voted to  the  "  Consequences  of  Chronic  Suppuration  of  the 
Middle  Ear."  The  subject  of  "Aural  Polypi"  will  also  be  de- 
ferred until  a  subsequent  chapter,  for  they  are  also  much  more 
frequently  the  result  of  inflammation  of  the  middle  ear,  than  of 
disease  of  the  external  auditory  canal.  Otitis  externa  is  the 
generic  term  for  all  the  various  forms  of  inflammation  of  the 
external  auditory  passage,  but  it  is  not  specific  enough  for  any 
exact  study  of  these  affections. 

Inflammations  of  the  external  auditory  canal  are  much  more 
rare  than  those  of  the  middle  ear  ;  of  6,800  cases  of  the  different 


124  STATISTICS   OF   INFLAMMATION   OF   CANAL. 

varieties  of  aural  disease  observed  by  myself  in  private  prac- 
tice, but  387  were  cases  of  inflammation  of  the  auditory  canal. 
This  proportion  varies  somewhat  from  the  statistics  of  other 
authors  and  those  of  public  institutions. 

In  the  Manhattan  Eye  and  Ear  Hospital,  during  the  past  nine- 
teen years,  there  were  examined  20,103  cases  of  aural  disease. 
Of  these  1,060  were  cases  of  inflammation  of  the  external  audi- 
tory canal.  This  does  not  include  cases  of  impacted  cerumen  or 
foreign  bodies,  or  inflammations  which  had  their  origin  in  the 
parts  beyond  and  extended  to  the  canal.  Including  inspissated 
cerumen  and  foreign  bodies,  there  were  3,538  cases  of  affections 
of  the  external  canal,  or  about  one-sixth  of  the  whole  number. 

Dr.  Biickner,  of  Gottingen,  has  compiled  a  table  of  reports 
from  various  authorities.1  In  a  total  number  of  58,645  cases  of 
diseases  of  the  ear  thus  reported,  there  were  14,905,  or  25.5  per 
cent.,  of  affections  of  the  external  ear. 

The  highest  percentage  of  diseases  of  the  external  ear  in 
Biickner's  tables  is  39.5  (Ocker),  the  lowest  13.3  (Roosa).  In 
Wilde's  tables,2  also  quoted  by  Biickner,  the  percentage  of  ex- 
ternal affections  is  very  high,  55.8.  Since  the  time  of  Wilde  it  is 
undoubtedly  true  that  our  means  of  diagnosis  are  better,  and  we 
are  enabled  to  transfer  many  cases  from  the  column  of  the  ex- 
ternal auditory  canal,  to  that  of  the  middle  ear. 

Some  writers  speak  of  the  inflammations  of  the  external 
auditory  passage  as  being  catarrhal  in  their  nature-;  but  as 
Troltsch  strongly  insists,  and  as  has  already  been  said  in  the 
description  of  the  anatomy  of  the  auditory  canal,  there  cannot  be 
a  catarrhal  inflammation  where  there  is  no  mucous  membrane. 
The  lining  of  this  passage  is  integument,  and  in  no  proper  sense 
can  we  speak  of  a  catarrh  of  the  integument. 

An  account  of  diffuse  or  general  inflammation  of  the  exter- 
nal auditory  canal  will  first  be  given. 

DIFFUSE  INFLAMMATION. 

Symptoms. — The  subjective  symptoms  of  diffuse  inflamma- 
tion of  the  external  auditory  canal  are  itching  sensations  in  the 
canal,  pain,  and  a  sense  of  fulness  and  heat. 

I  speak  of  these  symptoms  in  the  order  in  which,  on  careful 
examination  of  the  history  of  the  cases,  I  have  found  they  usu- 
ally appear.  It  is  true  that  patients  often  give  a  period  later 
than  that  in  which  the  itching  sensations  occurred,  as  the  one 


1  Archiv  fur  Ohrenheilkunde,  1883. 
1  Text-book,  English  edition,  p.  114. 


DIFFUSE   INFLAMMATION.  125 

in  which  their  ears  first  troubled  them,  but  ears  in  a  normal 
state  have,  so  to  speak,  no  sensations  ;  that  is  to  say,  they  are 
not  thought  of,  and  need  no  especial  care.  When  an  ear  be- 
gins to  require  something  to  relieve  itching  sensations,  it  is 
already  diseased. 

The  objective  symptoms  are  impairment  of  hearing,  redness 
of  the  canal  and  perhaps  of  the  membrana  tympani,  swelling, 
and,  at  a  subsequent  period,  suppuration  of  the  epidermis  and 
integument.  In  the  lower  part  of  the  canal,  where  we  have  the 
•density  and  tenseness  of  periosteum,  the  pain  may  be  as  severe 
as  that  from  inflammation  of  the  lining  of  the  tympanic  cavity, 
or  as  that  occurring  in  paronychia. 

Prolonged  suppuration  of  the  integument,  or  even  suppura- 
tive  action  that  has  been  of  short  duration,  but  violent,  may 
produce  polypi,  or,  as  I  prefer  to  call  them,  granulations,  in  the 
external  auditory  canal.  I  have  seen  several  such  cases.  One, 
that  of  a  lady,  was  complicated  by  a  precedent  inflammation  of 
the  cavity  of  the  tympanum ;  but  the  inflammation  of  the  ex- 
ternal auditory  canal  was  an  independent  one.  Very  large  gran- 
ulations, or  polypi,  sprang  up  in  a  few  days  after  a  poultice  had 
been  applied.  This  poultice  was  ordered  by  the  attending  physi- 
cian to  relieve  the  initial  pain  of  an  inflammation  of  the  canal, 
such  as  sometimes  occurs  from  the  continued  instillation  of 
astringents.  It  was  applied  for  some  days  through  a  misunder- 
standing of  the  damage  that  might  ensue,  and  very  large  gran- 
ulations formed. 

Another  case  occurred  in  an  Irish  laborer,  whom  I  saw  while 
I  held  a  clinic  in  the  University  Medical  College.  I  removed  a 
large  polypus  from  the  canal,  which  the  patient  stated  posi- 
tively had  occurred  in  a  few  days,  and  that  he  had  never  pre- 
viously suffered  from  disease  of  the  ear.  After  the  treatment 
had  progressed  for  some  time,  I  found  that  the  inflammation 
was  confined  to  the  canal  and  the  outer  layer  of  the  drum-head, 
and  that  his  statement  as  to  the  existence  of  previous  disease 
was  probably  correct.  I  could  find  no  cause  for  the  rapid  course 
of  the  inflammation. 

A  third  case  I  saw  at  the  Brooklyn  Eye  and  Ear  Hospital. 
The  trouble  in  the  ear  had  lasted  seven  days,  and  here  also  there 
was  a  large  polypus.  The  fourth  case  was  that  of  a  lady  whom 
I  saw  in  private  practice.  She  suffered  from  what  she  supposes 
to  have  been  an  abscess  or  furuncle  of  the  external  meatus.  It 
was  lanced,  and  then  poultices  were  applied.  I  saw  her  six  days 
after.  She  had  used  the  poultices  nearly  the  whole  of  the  six 
days.  I  found  the  canal  blocked  up  by  a  polypus  as  large  as  a 
filbert,  growing  from  the  anterior  wall  of  the  canal.  The  final 


126  DIFFUSE   INFLAMMATION. 

result  of  this  case  in  deformity  of  the  auricle,  is  seen  in  the  en- 
graving on  page  113. 

The  practitioner  need  give  himself  no  uneasiness  about  the 
occurrence  of  these  granulations.  As  a  rule,  they  subside  spon- 
taneously. If  not,  when  well  pedunculated  they  are  easily  re- 
moved with  a  curette  with  sharp  edges. 

The  microscopic  appearances  of  the  growths  are  identical 
with  those  of  polypi  springing  from  the  mucous  membrane  of 
the  cavity  of  the  tympanum,  which  will  be  fully  discussed  in  a 
subsequent  chapter. 

Although  it  is  anticipating  somewhat  of  what  should  be  said 
under  the  head  of  treatment,  I  will  here  state  that  the  undoubted 
cause  of  these  growths,  in  two  of  the  cases  just  given,  was  the 
prolonged  use  of  the  poultices.  Troltsch  called  attention  to  the 
fact  that  poultices  produced  tedious  suppuration  ;  but  I  believe 
this  is  the  first  intimation  that  they  cause  the  sprouting  up  of 
exuberant  granulations  in  the  canal. 

Causes, — The  causes  of  the  diffuse  form  of  inflammation  are 
various.  Irritation  of  the  ear  by  means  of  ear-picks,  by  hair- 
pins, favorite  instruments  with  women  ;  the  instillation  of  such 
agents  as  Haarlem  oil,  Cologne  water,  camphorated  oil,  and  so 
on,  are  frequent  causes  of  an  inflammation  of  this  part. 

Surf-bathing  sometimes  is  a  cause  of  inflammation  of  the 
auditory  canal  and  outer  layer  of  the  membrana  tympani,  either 
with  or  without  an  inflammation  of  the  middle  ear.  This  is  not 
apt  to  occur  among  careful,  intelligent  persons.  In  surf -bathing 
the  bather  should  take  a  little  pains  that  the  shock  of  the  waves 
does  not  come  upon  the  side  of  the  head,  but  in  front.  When 
the  ears  are  .filled  with  water,  they  should  be  carefully  dried. 
Prolonged  and  repeated  diving  should  be  avoided,  especially  by 
those  who  have  sensitive  or  diseased  ears.  Caps  of  oiled  silk 
and  plugs  of  oiled  cotton  are  also  useful  in  bathing  to  those 
whose  ears  are  sensitive  to  the  entrance  of  salt  water.  In  seri- 
ous cases  of  aural  disease,  sea-bathing  must  be  prohibited.  This 
subject  will  be  again  alluded  to  in  the  discussion  of  diseases  of 
the  middle  ear. 

There  is  probably  some  antecedent  inflammation  of  the  in- 
tegument which  causes  a  resort  to  those  agents,  to  relieve  the 
troublesome  itching  sensations.  Cold  draughts  of  air  are  often 
spoken  of  as  causes  of  inflammation  of  the  outer  canal ;  but  such 
influences  are  more  apt  to  produce  an  inflammation  of  the  naso- 
pharyngeal  space,  and  through  that  of  the  middle  ear.  In  fact, 
the  causes  of  external  otitis  diffusa  seem  to  be  chiefly  local,  if  I 
may  so  speak  ;  that  is,  the  disease  is  caused  by  mechanical  causes 


DIFFUSE   INFLAMMATION.  127 

acting  locally.  There  may,  however,  be  an  antecedent  eczema- 
tous  inflammation  before  the  diffuse,  non-eruptive  form  begins. 

A  diffuse  inflammation  of  the  external  auditory  canal,  quite 
often  occurs  during  the  latter  part  of  the  course  of  an  acute  sup- 
puration of  the  middle  ear,  but  it  usually  subsides  without  spe- 
cial treatment. 

Of  late  an  apparatus,  consisting  of  a  very  small  sponge,  at- 
tached to  an  appropriate  handle,  and  called  an  aurilave,  has  been 
devised,  and  is  sold  largely  by  apothecaries  as  an  instrument 
for  cleansing  the  ear.  It  does  a  great  deal  of  harm.  By  its  use 
the  secretions  are  packed  in  the  ear,  and  inflammation  of  the 
integument  or  inspissation  of  the  cerumen  is  very  often  caused. 

Physicians  are  often  asked  if  the  outer  ear  should  be  pro- 
tected from  the  cold  air  by  a  plug  of  cotton,  ear-muffs,  or  simi- 
lar means.  The  beginning  of  aural  inflammation  is  rarely  from 
the  auditory  canal,  although  the  auricle  is  sometimes  frozen 
from  exposure  to  cold.  If,  however,  a  person  sit  -in  a  railway 
carriage  which  is  going  very  fast,  with  the  ear  next  to  an  open 
window,  or  if  the  auditory  -canal  and  membrana  tympani  be 
exposed  in  any  similar  manner  to  a  draught  of  air,  an  inflam- 
mation of  the  canal  and  of  the  tympanic  cavity  may  ensue.  But 
when  there  is  no  such  draught  upon  the  ear,  as,  for  instance, 
when  a  person  is  walking  or  driving  in  the  open  air,  there  is  no 
need,  unless  there  is  danger  that  the  auricle  will  be  frost-bitten, 
or  there  is  a  strong  wind  blowing,  of  using  a  covering  to  the 
meatus  auditorius  any  more  than  to  the  nostrils.  The  natural 
curvatures  of  the  canal  will  prevent  a  current  of  air  from  reach- 
ing the  drum-head.  This  is,  however,  only  true  as  respects 
healthy  ears.  In  cases  of  chronic  aural  catarrh,  and  in  the 
other  kinds  of  troubles  of  the  middle  ear,  the  canals  sometimes 
become  very  sensitive  to  the  cold,  and  require  protection  when 
healthy  ears  do  not.  When  no  inconvenience  is  felt  from  allow- 
ing the  ears  to  remain  uncovered,  it  is  better  to  leave  them 
without  protection.  The  habit  of  plugging  the  auditory  canals 
with  cotton  on  every  slight  pretext  is  a  bad  one,  because  it  is 
apt  to  irritate  the  integument  and  to  cause  the  ears  to  be  over- 
sensitive, and  it  may  produce  dermatitis.  As  I  have  said,  we 
do  not  usually  get  an  inflammation  of  the  ear  from  an  exposure 
of  the  auditory  canal,  but  from  such  causes  as  wet  feet,  an  ex- 
posure of  the  whole  surface  of  the  body,  and  so  on. 

Cousins,  of  London,1  recommends  a  little  conical  cap  of  vul- 
canite, made  of  flesh-colored  material,  as  a  protector  to  the  audi- 
tory canal  from  cold  and  noise,  and  from  water  in  bathing.  This 


British  Medical  Journal,  December  31,  1881. 


128 


DIFFUSE   INFLAMMATION. 


protector  seems  to  me  to  be  an  excellent  contrivance  for  use  in 
the  cases  where  protection  of  this  kind  is  needed. 

There  is  altogether  too  much  solicitude  on  the  part  of  moth- 
ers and  other  persons  as  to  the  cleanliness  of  their  children's  or 
their  own  ears.  The  auricle  and  the  edges  of  the  opening  into 
the  canal,  which  are  about  all  that  the  little  finger  will  reach, 
are  the  only  parts  of  the  organ  that  require  cleansing  when  the 
ears  are  in  a  state  of  health.  Any  further  manipulations  with 
towels,  ear-spoons,  and  so  on,  are  meddlesome,  and  may  become 
dangerous  to  the  health  of  the  canal. 

Treatment. — An  attack  of  diffuse  inflammation  of  the  exter- 
nal auditory  canal  (otitis  externa  diffusd)  in  an  adult  may  often 


FIG.  43. 

be  cut  short  by  the  use  of  leeches.  They  should  be  applied  as 
Wilde  long  ago  pointed  out,  not  on  the  mastoid  process,  but  on 
the  tragus,  for  the  reason  which  Troltsch  gives,  that  in  this 
place  the  vessels  which  supply  the  canal  and  outer  layer  of 
membrana  tympani  are  most  conveniently  and  surely  reached. 
Leeches  in  this  form  of  disease  are  not  as  certain  to  afford  relief, 
however,  as  when  used  for  an  inflammation  of  the  middle  ear ; 
when,  as  we  shall  see,  they  exert  an  almost  magical  influence, 
so  rapid  is  their  effect.  In  the  early  stages  of  the  disease,  when 
the  pain  is  severe,  and  suppuration  has  not  yet  occurred,  but  the 
canal  is  red,  swelled,  and  sensitive,  great  benefit  will  be  pro- 
duced by  scarifications  of  the  cartilaginous  wall.  This  scarifi- 
cation is  made  with  a  tenotomy  knife.  The  incisions  should  be 
from  three-fourths  to  an  inch  long  on  the  walls  of  the  canal,  as 
recommended  by  Gruber,  of  Vienna.  Warm  water  should  also 
be  allowed  to  run  into  the  ear,  by  means  of  the  fountain  syr- 
inge, the  Fayette  Taylor  douche,  Clark's  douche,  or  any  similar 


AURAL  DOUCHE. 


129 


means.  When  patients  are  told  to  apply  warm  water  to  the 
ear,  unless  they  are  particularly  instructed,  they  will  almost  in- 
variably use  the  syringe,  thinking  that  is  the  way  in  which  the 
water  is  to  be  applied  ;  but  what  is  required  is  the  steady  flow 
of  warm  water  upon  the  part,  and  this  is  best  attained  by  means 
of  the  douche.  Patients  should  be  instructed  in  its  use,  and  es- 
pecially should  they  be  told  that,  unless  the  auricle  is  kept  on 
the  stretch,  so  that  the  walls  of  the  canal  are  apart,  the  water 
will  not  enter  the  ear.  I  am  thus  particular  in  my  advice,  be- 
cause, even  to  this  day,  I  find  that  many  physicians  advise  that 

warm  water  be  applied  to  the  ear  by 
means  of  the  piston  syringe  instead  of 
by  a  douche.  As  has  been  seen  in  the 
first  chapter,  Hippocrates  advised  the 
use  of  warm  water  to  the  ear  for  the 
relief  of  pain,  but  it  fell  into  unde- 
served disuse  until  the  value  of  its  ap- 
plication was  reinforced  in  the  minds 
of  a  profession  filled  with  the  idea  of 
the  virtues  of  composite  "ear-drops." 
The  fountain  syringe  and  Taylor's 
douche  are  more  convenient  than  the 
solid  cup  making  up  Clarke's  douche, 
and  they  have  pretty  generally  super- 
seded the  latter. 

The  Fayette  aural  douche  l  consists  of  two 
siphons,  so  arranged  that  the  flow  starts  at  the 
same  moment  in  each  ;  and  while  one  siphon 
conveys  the  water  into  the  ear  the  other  lifts 
it  gently  out,  without  friction  or  pressure  upon 
the  inflamed  tissiies. 

In  the  figure,  B  C  represents  the  ear-piece,  which  is  made  of  suitable  size  and 
shape.  Two  holes  are  bored  through  it,  one  lying  above  the  other  when  it  is  in 
its  proper  position.  On  each  of  the  two  projections  at  the  larger  end,  a  piece 
of  flexible  rubber  tubing  (such  as  is  used  for  nursing-bottles),  about  four  feet 
long,  is  fitted.  At  the  small  end  of  the  ear-piece  the  division  between  the  holes 
is  cut  back  about  one-eighth  of  an  inch,  so  that  placing  the  finger  over  this  end 
leaves  one  continuous  passage  from  the  top,  A,  to  the  bottom,  T).  With  the 
finger  over  the  small  end  of  the  ear-piece,  as  just  described,  when  water  is 
poured  into  the  funnel  A,  it  will  flow  directly  through  both  tubes,  and  come  out 
at  the  lower  end,  D,  in  the  drip-vessel.  When  all  the  air  has  thus  been  ex- 
cluded and  a  current  established,  the  funnel  A  is  dropped  into  the  basin  or 
pitcher  which  serves  as  a  reservoir,  and  a  single  siphon  is  formed.  The  rubber 
tubes  are  now  compressed  by  the  thumb  and  finger  at  E,  so  as  to  arrest  the 


FIG.  43. — Fayette  Douche. 


1  Archives  of  Otology,  Vol.  VIII.,  p.  355. 


130  AURAL   DOUCHE. 

flow,  the  finger  is  removed  from  the  end  BC,  and  the  ear-piece  is  inserted  into 
the  auditory  canal ;  then  letting  go  the  tubes  at  E,  a  double  siphon  is  instantly 
established,  AB  conveying  the  water  into  the  ear,  and  CD  carrying  it  out  by 
atmospheric  pressure.  Thus  the  resistance  and  pressure,  often  painful,  of  the 
in-coming  and  out-going  currents  is  avoided,  and  a  small  amount  of  constantly 
changing  water,  of  any  desired  temperature,  is  kept  in  contact  with  the  auditory 
•canal  and  drum-head.  Any  amount  of  water  desired  can  be  used  in  one  con- 
tinuous bath,  without  the  trouble  of  refilling  the  reservoir  several  times,  as  is 
so  often  required  in  using  the  fountain  syringe. 

Dr.  Taylor  invented  this  douche  while  under  my  care,  and 
he  found  it,  as  have  many  of  my  patients  since,  a  pleasanter 
method  of  using  a  warm  douche  to  the  ear  than  the  fountain 
syringe. 

Objections  are  made  by  some  writers  to  the  continuous  use 
of  warm  water  in  inflammations  of  the  canal,  but  my  faith  re- 
mains unshaken  in  the  great  value  of  the  warm .  or  even  hot 
douche  in  the  vast  majority  of  cases  of  acute  inflammation  of 
the  canal  and  tympanum,  and  I  recommend  it  to  the  profes- 
sion in  great  confidence  that  only  in  exceptional  cases  will 
they  be  disappointed  with  its  effects.  There  are  a  few  patients 
who  never  find  it  pleasant,  and  some  who  can  bear  it  only 
for  a  time,  but  most  patients,  even  young  children,  who  at 
first  object  to  its  use,  soon  find  in  the  warm  douche  a  source  of 
relief  from  pain  in  acute  inflammation  of  the  canal  or  middle 
ear. 

In  the  absence  of  the  cup,  a  bit  of  rubber  tubing  and  an  ordi- 
nary bowl,  by  the  application  of  the  principle  of  the  siphon,  will 
make  an  efficient  and  simple  'douche. 

The  value  of  the  aural  douche  is  by  no  means  limited  to 
cases  of  inflammation  of  the  outer  portions  of  the  ear.  In  acute 
inflammations  and  chronic  suppurations  of  the  middle  ear,  it 
becomes  a  very  valuable  means  of  alleviating  pain  and  of 
cleansing  the  ear.  For  the  latter  purpose  it  is  especially  valu- 
able among  children. 

If  the  use  of  the  leeches,  the  employment  of  scarification, 
and  the  warm  douche  do  not  wholly  subdue  the  pain — which 
is  quite  unlikely — a  small  flax-seed  poultice  may  be  applied  in 
the  meatus,  over  the  mastoid,  and  in  front  of  the  auricle  ;  but 
the  ear  should  not  be  covered  by  a  large  poultice,  as  is  often 
done,  for  reasons  that  have  been  already  fully  given.  A  poul- 
tice should  never  be  applied  to  or  on  the  ear  for  more  than  a 
few  hours.  They  are  almost  as  dangerous  a  remedy  in  aural 
as  in  ophthalmic  practice,  where  they  have  caused  the  loss  of 
many  eyes. 

At  night  the  ear  should  be  kept  warm  by  wrapping  it  in  cot- 


DIFFUSE   INFLAMMATION.  131 

ton,  and  the  patient  should  lie  on  a  pillow  that  is  warmed  from 
beneath,  by  means  of  a  rubber  bag  filled  with  hot  water,  or  some 
similar  contrivance.  A  plug  of  cotton  saturated  in  glycerine  or 
smeared  with  diachylon  ointment,  is  also  of  value  in  subacute 
cases.  By  attention  to  these  details  much  suffering  will  be 
spared  the  patient,  and  the  course  of  the  affection  will  be  short- 
ened. In  addition  to  the  local  treatment,  it  will  sometimes  be 
necessary,  although  not  often,  to  give  one  of  the  preparations 
of  morphine,  or  a  dose  of  chloral  internally.  I  -have  not  found 
much  advantage  from  the  addition  of  narcotics  to  the  warm 
water  instillations,  although  there  may  be  some  benefit  from 
their  use. 

In  severe  cases  of  inflammation  of  the  external  ear  occur- 
ring in  adults,  I  have  lately,  at  the  suggestion  of  Dr.  W.  S.  Ely, 
of  Rochester,  used  at  bed-time,  to  be  repeated  every  two  hours, 
if  necessary,  a  formula,  embracing  sulphate  of  morphia,  hydrate 
of  chloral,  and  bromide  of  sodium  in  each  dose,  with  the  effect  of 
securing  sound  sleep  in  cases  where  other  means  for  the  relief  of 
pain  did  not  enable  the  patient  to  get  but  snatches  of  repose.  The 
wit  of  the  medical  attendant  will  sometimes  be  taxed  to  its  ut- 
most in  order  to  secure  rest  for  his  patient  suffering  from  acute 
inflammation  of  the  auditory  canal.  Indeed,  I  find  it  generally 
easier  to  secure  prompt  relief  from  a  pain  in  the  ear,  arising 
from  an  inflammation  of  the  tympanic  cavity  arjd  mastoid  cells 
than  from  a  diffuse  or  furuncular  inflammation  of  the  canal. 
Yet,  in  all  the  anxiety  to  relieve  pain,  the  physician  may  derive 
much  consolation  from  the  knowledge  that  the  patient  will  ulti- 
mately recover  with  perfect  hearing,  if  the  auditory  canal  and 
drum-head  be  the  only  parts  seriously  involved. 

The  popular  remedies  for  ear-ache,  dependent  upon  whatever 
cause,  are  usually  sweet-oil  and  laudanum,  molasses,  Haarlem 
oil,  glycerine,  and  a  roasted  onion.  The  oil,  laudanum,  and 
molasses  are  tolerably  efficient ;  but  although  they  are  useful  in 
their  property  of  stilling  pain,  they  are  far  inferior  to  the  leeches, 
scarification,  and  warm  water.  I  have  seen  children,  who  had 
been  suffering  from  severe  pain  in  the  ear,  drop  off  to  sleep  in  a 
few  moments  after  a  tablespoonful  of  warm  water  was  poured 
into  the  ear ;  and  yet  I  am  very  sorry  to  say  that  there  are  some 
rare  cases  where  warm  water  seems  to  aggravate  the  pain  ;  the 
leeches  sometimes  also  fail  us  in  the  disease  now  under  discussion. 

The  onion  acts  just  as  the  conical  flax-seed  poultice,  and  may 
be  resorted  to  if  the  warm  water  fails,  and  leeches  are  not  to  be 
had.  Haarlem  oil,  and  all  similar  stimulating  applications,  do 
nothing  but  harm,  and  increase  the  sufferings  of  the  distressed 
patient.  The  laity  resort  to  such  applications,  and  submit  for 


132  DIFFUSE  INFLAMMATION. 

days  to  pain  in  the  ear,  without  going  to  a  physician,  because 
they  have  been  taught  by  sad  experience  that  doctors  pay  very 
little  attention  to  an  ear-ache — and  yet  what  pain  is  worse  ? 
Warm  vapor  of  any  kind,  the  vapor  of  chloroform,  the  smoke 
from  a  cigar,  for  example,  is  very  grateful  to  an  inflamed  audi- 
tory canal  or  membrana  tympani;  and  a  steam  nebulizer  be- 
comes at  some  times  a  very  useful  adjuvant  in  treatment  of 
acute  aural  inflammations.  Sometimes  children,  who  awake  at 
night  with  ear-ache,  may  be  quieted  by  breathing  slowly  into 
the  auditory  canal. 

Some  practitioners  are  in  the  habit  of  indiscriminately  advis- 
ing blisters  behind  the  ear  in  all  forms  of  aural  disease,  whether 
acute  or  chronic.  I  formerly  supposed  that  they  were  not  of 
much  value  except  in  chronic  cases,  but  I  am  convinced  that 
harsh  as  is  the  remedy  apparently,  it  is  sometimes  very  efficient. 
The  following  case  is  one  almost  in  point,  and  I  do  not  now 
hesitate  to  advise  blisters  in  severe  inflammations  of  the  canal 
as  well  as  those  of  the  middle  ear. 

I  lately  saw  a  case  in  consultation  with  Dr.  S.  Beach  Jones, 
of  acute  catarrh  of  the  middle  ear,  occurring  in  the  course  of 
measles,  in  a  young  boy,  for  which  the  mother  had  applied  a, 
blister  over  each  mastoid,  and  apparently  with  good  effect.  In 
these  days  of  pleasant  remedies  this  seems  harsh  treatment,  but 
the  mother  and  ^the  boy  seemed  satisfied  with  what  Dr.  Jones 
and  I  would  have  hesitated  to  recommend.  I  only  object  to  blis- 
ters because  I  think  better  results  may  be  attained  with  milder 
means.  Their  efficacy  can  hardly  be  doubted  in  many  cases. 
Speedy  relief  from  the  severe  pain  of  otitis  is  as  imperative  as  in 
peritonitis  or  iritis,  and  I  have  dwelt  on  the  various  remedies  at 
some  length,  in  order  that  the  practitioner  may  be  at  no  loss 
for  some  agent  that  will  cut  short  the  inflammatory  action.  I 
will  tabulate  the  remedies  in  the  order  that  I  consider  them 
valuable:  1.  Leeches;  2.  Warm  douche;  3.  Blisters  ;  4.  Scarifica- 
tion ;  5.  Conical  poultice  in  the  canal ;  6.  Steam  or  warm  vapor ; 
7.  Narcotics. 

Dr.  A.  D.  Williams  recommends  the  use  of  a  solution  of  a 
sulphate  of  atropia,  two  to  four  grains  to  the  ounce,  which  is 
dropped  into  the  auditory  canal  as  a  remedy  for  the  relief  of  the 
pain  from  aural  inflammation.  I  have  found  this  an  uncertain 
remedy,  but  in  some  cases  it  quiets  pain.  I  think,  however, 
that  it  is  more  apt  to  be  of  use  in  the  rare  cases  of  neuralgia  of 
the  ear — cases  where  there  is  pain  without  the  usual  signs  of  in- 
flammation— than  in  external  otitis.  Knapp '  reports  a  case  of 

1  Archives  of  Otology,  Vol.  XI.,  p.  33. 


SYRINGING  THE   EAR. 


133 


transient  poisoning  from  the  instillation  of  a  few  drops  of  atropia 
in  the  auditory  canal.  The  patient  was  a  woman  of  twenty-five, 
in  good  health.  Four  hours  and  a  half  after  dropping  in  a  half 
per  cent,  solution  of  sulphate  of  atropia  the  hands  of  the  patient 
began  to  swell  and  become  stiff,  the  face  became  scarlet,  her 
throat  dry  and  so  forth.  The  symptoms  abated  in  about  five 
hours.  The  pain  in  the  ear  was  relieved  and  a  subsequent  in- 
stillation of  a  weaker  solution  had  no  evil  effect.  The  auditory 


FIG.  44.— Syringe  for  the  Ear. 

canal  and  membrana  tympani  were  free  from  excoriation  and 
ulcer.  We  sometimes  see  this  extreme  susceptibility  to  atropia, 
but  it  is  so  rare,  that  I  do  not  think  it  is  to  be  regarded  if  it 
becomes  necessary  to  use  it  for  the  relief  of  pain.  I  wish  I 
could  say,  that  it  had  often  proved  an  efficient  agent  in  my  hands 
for  the  relief  of  the  pain  of  otitis. 

Most  adult  patients  go  about  while  suffering  from  external 
diffuse  otitis.     During  the  more  acute  stages  it  would  be  better 


FIG.  45.— Reservoir  Syringe. 

to  keep  them  in-doors  and  in  bed.     If  this  can  be  accomplished, 
the  use  of  diaphoretics  will  aid  the  local  treatment. 

If,  in  spite  of  our  efforts,  suppuration  is  once  fairly  estab- 
lished, or  if  the  disease  has  advanced  to  this  point  when  first 
seen  by  the  practitioner,  we  must  endeavor  to  limit  the  suppu- 
ration. To  this  end  thorough  cleansing  of  the  ears  is  necessary. 
This  is  best  accomplished  by  syringing— a  simple  procedure,  but 
one  which  many  physicians  are  unable  to  carry  out  efficiently 


134  SYRINGING  THE   EAR. 

and  with  neatness.  The  appliances  necessary  for  a  thorough 
syringing  of  the  ear  are,  first,  a  good  syringe.  I  think  the  small 
piston  syringe  is  the  best,  and  I  do  not  advise  the  common  soft 
rubber  enema  syringe  called  "  Davidson's "  in  this  country. 
The  glass  syringes  are  of  no  use  whatever. 

Where  patients  are  likely  to  need  an  aural  syringe  for  a 
long  time,  it  is  better  to  advise  them  to  get  one  made  of  brass  or 
German  silver.  The  hard-rubber  syringes  are  carelessly  made 
as  a  rule.  Indeed,  the  practitioner  will  find  it  difficult  to  secure 
a  good  syringe  without  taking  some  pains,  for  even  the  metal 


FIG.  46.  —Method  of  Syringing  the  Ear. 

ones  sold  by  the  instrument  manufacturers  of  New  York  are  often 
very  carelessly  made.  Luer,  of  Paris,  sells  a  reservoir  syringe, 
represented  in  Fig.  45,  which  is  exceedingly  useful,  especially 
in  hospital  practice,  where  much  use  of  a  syringe  is  required. 

Then  we  need  a  bowl — a  small  one,  not  a  large  wash-bowl, 
but  one  such  as  is  used  as  a  finger-bowl — being  thin  and  easily 
held — and  a  receptacle  for  the  warm  water  which  is  to  be  used 
in  the  syringing  process.  No  towels  or  napkins  are  needed 
about  the  neck,  to  prevent  injury  from  the  water  ;  no  assistant 
beside  the  patient  is  required,  if  he  be  an  adult,  and  if  the  proce- 


SYRINGING  THE  EAR.  135 

dure  be  carried  out  as  will  be  described.  The  patient  being 
seated,  holds  the  bowl  well  under  the  auricle,  in  the  hollow  just 
under  the  lobe,  keeping  the  head  perfectly  straight,  and  using 
both  hands  to  steady  the  vessel.  The  surgeon  should  thoroughly 
straighten  the  auditory  canal  with  the  left  hand,  and  placing  the 
nozzle  of  the  syringe  well  into  the  meatus,  direct  the  stream, 
with  the  right,  down  to  the  membrana  tympani.  It  is  well  to 
prepare  the  patient  for  the  shock  of  the  water,  by  allowing  a 
part  of  the  first  syringeful  to  pass  into  the  concha,  and  not  into 
the  canal. 

It  will  be  seen  that  no  patient  is  capable  of  thoroughly 
syringing  his  own  ear,  and  that  no  person  who  has  not  been 
taught  the  simple  process  will  be  able  to  accomplish  the  object 
for  which  syringing  is  undertaken,  that  is,  the  cleansing  of  the 
auditory  canal  and  the  outer  surface  of  the  membrana  tympani, 
and,  if  it  be  perforated,  the  tympanic  cavity.  Notwithstanding 
these  facts,  patients  suffering  from  an  ulcerative  process  in  the 
ear,  and  who  require  the  daily  removal  of  the  pus  as*  an  essen- 
tial to  recovery,  are  often  sent  away  without  other  instruction 
than  the  advice  to  syringe  the  ear.  It  is  almost  as  difficult  for  a 
person  to  properly  syringe  his  own  ear  as  to  cauterize  his  own 
palpebral  conjunctiva.  We  certainly  should  never  think  of 
leaving  the  latter  manipulation  to  any  but  a  person  who  had 
been  taught  to  manage  it  properly. 

The  ear  affected  with  chronic  external  otitis  should  be 
syringed  from  one  to  three  times  daily  while  the  secretion  is  at 
its  height.  It  should  afterward  be  carefully  dried  by  means  of 
absorbent  cotton,  upon  a  cotton-holder.  The  cotton-holder  may 
be  made  of  wood  or  metal.  If  the  end  be  roughened,  the  cotton 
may  be  more  easily  kept  upon  it.  Neither  syringing  nor  cleans- 
ing with  a  cotton-holder  need  be  at  all  a  painful  process  ;  it  must 
be  done  gently,  and  this  direction  applies  to  all  the  manipulations 
upon  the  ear.  A  wise  patient  will  prefer  to  leave  his  case  to 
nature  and  to  his  own  care,  than  to  trust  his  ear  to  a  physician 
who  handles  it  roughly.  As  I  have  before  said,  in  discussing 
another  subject,  one  of  the  best  means  of  becoming  a  gentle  and 
successful  aural  surgeon  is  to  submit  one's  self  to  the  use  of  the 
Eustachian  catheter,  the  speculum,  syringe,  and  cotton-holder 
before  beginning  to  practise  upon  patients. 

The  agents  which  may  be  used  in  checking  ulceration  in  the 
canal  are  numerous.  I  perfer  solutions  of  nitrate  of  silver,  of 
alum,  and  of  the  sulphates  of  zinc  and  copper,  to  the  others.  The 
nitrate  of  silver  I  use  in  strong  solutions,  from  20  to  40  grains  to 
the  ounce,  pencilled  over  the  parts  ;  the  sulphates  and  the  alum 
in  solutions  of  from  1  to  4  grains  to  the  ounce,  instilled  into  the 


136  CHRONIC   SUPPURATION   OF   CANAL. 

ear.  The  choice  of  the  astringent  is,  however,  much  less  im- 
portant than  the  thorough  removal  of  the  pus,  which  should  be 
done  at  least  three  times  a  week,  and,  if  possible,  daily,  by  the 
physician  himself.  The  patient  or  his  attendants  should  use 
the  syringe  from  once  to  four  times  a  day,  according  to  circum- 
stances. 

What  may  be  done  for  a  neglected  suppuration  of  the  audi- 
tory canal,  by  the  mere  daily  removal  of  the  pus  and  the  appli- 
cation of  a  caustic  or  astringent,  however  many  alteratives 
and  other  constitutional  remedies  may  have  been  taken  in  vain, 
is  sometimes  marvellous.  Astringent  or  absorbent  powders  are 
more  applicable  to  diseases  of  the  middle  ear  than  to  those  of  the 
canal. 

Indeed,  careful  and  thorough  cleansing,  without  the  subse- 
quent use  of  astringents,  will  often  effect  a  cure.  It  is  now  my 
habit  to  delay  the  use  of  astringents  until  I  am  sure  that  no  prog- 
ress in  a  case  is  being  made  without  them.  In  some  cases  I  am 
never  compelled  to  resort  to  any  other  treatment.  This  is  some- 
times overlooked  by  those  who  attach  much  importance  to  the 
use  of  constitutional  remedies  or  internal  medication  in  the 
treatment  of  localized  suppurations  of  the  ear.  A  suppuration  of 
the  external  auditory  canal,  like  the  same  disease  in  the  middle 
ear,  has  a  natural  course,  which  often  needs  mere  guidance  to 
lead  it  to  a  successful  termination.  To  study  this  course  is  more 
important  for  the  young  practitioner  than  to  learn  what  drugs 
are  said  to  be  of  service  in  certain  diseases. 

If  the  pain  be  severe  and  the  tension  evidently  marked,  the 
proper  treatment  is  incision.  A  narrow  knife  is  a  very  good 
one  for  the  operation.  The  incision  should  be  deep  and  free.  In 
very  delicate  and  sensitive  patients  it  may  be  well  to  put  the 
patient  under  the  primary  anaesthetic  effect  of  sulphuric  ether 
before  making  the  cut.  This  is  done  by  causing  the  patient 
to  inhale  the  fumes  of  the  ether  in  the  usual  way,  holding  up 
the  arm  while  inhaling.  When  the  arm  drops,  usually  in 
twenty  seconds,  the  incision  may  be  made  without  causing  pain, 
while  not  enough  ether  will  have  been  taken  to  cause  nausea 
or  vomiting  or  other  serious  inconvenience.  In  place  of  the 
ether  patients  may  take  a  dose  of  brandy  or  whiskey  before  sub- 
mitting to  this  painful  operation.  I  dare  not  recommend  any 
other  anaesthetic  than  sulphuric  ether,  even  after  hearing  all 
that  is  said  for  chloroform,  bromide  of  ethyl,  and  the  rest. 

In  the  writings  of  Dr.  Buck '  and  others,  some  stress  is  laid 
upon  what  is  termed  "  desquamative  inflammation"  of  the  ex- 

1  Diseases  of  the  Ear,  p.  86  ;  also  Medical  Record,  December  15,  1877. 


DESQUAMATIVE   INFLAMMATION.  137 

iernal  auditory  canal.  A  separate  form  of  diffuse  inflammation 
is  made  by  this  method  of  naming  diseases,  but  I  continue  to 
regard  the  desquamative  variety  as  merely  one  of  the  very  com- 
mon stages  of  diffuse  inflammation.  A  certain  amount  of  des- 
quamation  must  occur  in  any  severe  inflammation  of  the  integu- 
ment of  the  canal.  The  kind  of  desquamation  described  by  Buck, 
I  have  often  observed  in  cases  of  aspergillus  of  the  canal,  and 
also  after  eczema  and  impacted  cerumen.  I  think  bichloride  of 
mercury,  gr.  ^  to  gr.  £  ad  aq.  f  j.,  and  nitrate  of  silver  and  pure  al- 
cohol, particularly  well  adapted  for  the  treatment  of  these  cases. 
The  practitioner  should  always  be  on  his  guard,  lest  he  mis- 
take a  chronic  suppuration  in  the  middle  ear  for  one  of  the 
auditory  canal,  with  an  intact  membrana  tympani.  It  will  be 
.seen  by  the  statistics  in  the  chapter  on  the  former  disease,  that 
&  long-continued  suppuration  in  the  ear  usually  has  its  origin, 
not  in  the  canal  or  outer  layer  of  the  drum-head,  but  in  the 
cavity  of  the  tympanum,  whence  it  advances  and  perforates  the 
membrana  tympani.  Chronic  suppuration  in  the  external  audi- 
tory canal,  contrary  to  what  has  often  been  written,  and  con- 
trary to  the  opinion  of  most  practitioners  with  whom  I  have 
conversed  on  this  subject,  is,  judging  from  my  experience,  a  rare 
disease.  When  it  does  exist,  it  is  almost  always  curable,  if  prop- 
erly treated,  by  the  free  use  of  the  warm  douche,  astringents,  and 
leeches,  if  need  be. 


•CIRCUMSCRIBED   INFLAMMATION,   OR   FURUNCLES   OF  THE   EXTERNAL 

AUDITORY   CANAL. 

By  circumscribed  inflammation  occurring  in  this  part  we 
.simply  mean  furuncles.  They  generally  arise  in  connection 
with  the  existence  of  furuncles  in  other  parts  of  the  body,  and 
^.re,  like  them,  very  painful.  They  also  produce  impairment  of 
the  hearing  by  mechanically  closing  the  auditory  canal.  Tinni- 
tus aurium — noise  in  the  ears — a  symptom  which  is  apt  to  be  very 
troublesome  in  almost  all  other  aural  affections,  is  not  generally 
present  when  furuncular  inflammation  exists.  It  may  be,  how- 
ever, after  the  pus  from  the  boil  has  been  evacuated,  and  some 
of  it,  perhaps,  remains  in  the  canal  and  presses  upon  the  mem- 
brana tympani,  and  through  it  upon  the  ossicula  audit  us  and 
auditory  nerve.  The  tinnitus  is  absent  in  the  early  stages,  be- 
cause there  is  no  pressure  exerted  upon  the  drum-head  by  a  cir- 
cumscribed swelling  of  the  canal. 

There  will  be  no  difficulty  in  the  diagnosis  if  the  ear  be  ex- 
amined by  means  of  the  otoscope.  One  or  niore  circumscribed 
swellings  are  found  in  the  calibre  of  the  canal.  Their  usual 


138  FURUNCLES. 

situation  is  a  point  near  the  tragus,  on  the  anterior  wall,  and 
we  may  have  two  or  more  at  a  time. 

The  proper  treatment  is  to  make  an  incision  at  as  early  a 
period  as  possible,  and  then  to  continuously  apply  warm  water, 
giving  the  ear  an  uninterrupted  warm  bath,  as  it  were.  It 
makes  no  difference  whether  pus  or  blood  be  evacuated  by  the 
incision.  The  relief  following  is  generally  immediate  in  either 
case.  If  the  pus  be  deeply  situated  it  will  be  better  to  make 
the  incision  with  a  scalpel,  cutting  downward.  If  it  be  near  the 
surface  a  bistoury  may  be  used,  and  the  cut  made  from  below 
upward.  The  ear  should  be  syringed  with  warm  water  after  the 
hemorrhage  has  ceased,  and  carefully  dried  with  the  cotton- 
holder,  or  the  impairment  of  hearing  and  sensations  of  fulness 
will  be  greater  than  before  the  opening  was  made. 

After  the  furuncle  is  opened,  and  the  pain  caused  by  it  ha& 
disappeared,  it  is  well  to  smear  the  passage  with  ointment,  in 
order  to  hasten  the  softening  of  the  indurated  tissue  surround- 
ing the  furuncle,  but  as  long  as  pain  continues  the  use  of  warm 
water  should  be  persisted  in  by  means  of  the  aural  douche.  The 
thorough  cleansing  will  usually  relieve  the  impairment  of  hear- 
ing caused  by  the  swelling  and  closure  of  the  canal,  while  the 
incision  and  douche  will  cut  short  the  pain.  Each  new  furuncle 
is  of  course  to  be  treated  in  the  same  way.  Sometimes  steam, 
conducted  into  the  canal  from  any  suitable  vessel,  is  of  great 
comfort  to  the  inflamed  part. 

Leeches  are  not  usually  of  much  service  in  furuncular  in- 
flammations of  the  canal.  Warm  water  is  not  always  well  borne, 
but  in  the  majority  of  cases  it  is  of  the  greatest  value  in  palliat- 
ing this  troublesome  affection.  In  this  respect  I  cannot  agree 
with  Politzer,1  who  thinks  the  warm  douche  gives  rise  to  fresh 
eruptions.  After  all  my  experience  in  this  painful,  although 
not  dangerous  affection,  I  still  hold  to  the  knife,  warm  water, 
small  poultices  in  the  meatus  and  in  front  and  behind  the 
auricle,  and  the  internal  administration  of  narcotics,  as  being, 
on  the  whole,  the  best  means  of  treatment. 

Dr.  Buck  *  thinks  that  we  cannot  expect  the  same  relief  from 
an  incision  into  the  auditory  canal  as  that  made  in  paronychia, 
because  "  a  comparatively  unyielding  cylinder  of  cartilage  sur- 
rounds the  inflamed  tissues  and  renders  relaxation  of  the  parts 
almost  an  impossibility."  I  think  there  will  be  no  difficulty  in 
relaxing  the  tense  point,  if  the  incision  be  made  through  it.  In 
order  to  secure  this,  the  surgeon  should  feel  about  very  care- 
fully with  a  probe  for  the  most  sensitive  part  before  operating. 

1  Text-book,  Cassel's  translation,  p.  600.  z  Text-book,  p.  71. 


FURUNCLES — SULPHIDE   OF   CALCIUM.  139 

If  needful,  he  should  make  two  incisions  at  different  points  and 
be  sure  to  make  them  deep  enough.  If  the  inflammation  be  not 
plainly  circumscribed,  the  disease  will  have  passed  over  the 
narrow  boundary  line  between  this  and  diffuse  inflammation. 
If  incisions  are  then  useful,  several  must  of  necessity  be  made. 
A  plug  of  glycerine,  or  diachylon  ointment,  or  a  small,  finger- 
shaped,  flax-seed  poultice  is  of  much  service  after  the  incision. 

Buck  and  Politzer  have  seen  furuncles  of  the  ear  occurring 
in  persons  otherwise  in  good  health,  but,  as  I  have  already  said, 
I  consider  auditory  f urunculosis  to  be  an  indication  of  a  low  state 
of  the  system,  and  I  do  not  think  I  have  ever  seen  a  primary 
affection  of  this  kind  in  a  thoroughly  well  person.  When  such 
cases  come  to  me,  I  invariably  find  a  necessity  for  constitutional 
treatment.  It  is  not  unusual  to  observe  a  circumscribed  inflam- 
mation of  the  canal  after  a  tedious  or  severe  suppuration  of  the 
middle  ear,  or  rather  while  it  is  in  progress,  but  this  I  consider 
an  entirely  distinct  affection  from  that  which  is  now  being  dis- 
cussed. 

Ringer,1  in  an  article  upon  the  sulphides,  in  his  work  on 
therapeutics,  says  that  the  sulphides  appear  to  him  to  have  the 
property  of  preventing  and  arresting  suppuration.  He  thinks 
that  in  an  "inflammation  threatening  to  end  in  suppuration 
they  reduce  the  inflammation  and  avert  the  formation  of  pus." 
Based  upon  Ringer's  statements  many  cases  of  suppuration  of 
the  various  parts  of  the  ear  have  beent  reated  by  Sexton,  Bacon," 
Rupp,3  and  others,  and  reports  of  the  results  made  in  special 
and  general  journals.  These  writers  are  loud  in  their  praise  of 
the  value  of  the  drug  when  used  to  prevent  or  limit  suppuration 
in  the  ear.  The  Therapeutical  Society  of  New  York  reported 
on  the  whole  favorably  upon  the  results  of  the  drug  in  suppura- 
tions. I  have  given  the  sulphide  of  calcium  a  fair  trial,  and  I 
have  never  seen  any  benefit  whatever  from  its  use.  I  have  also 
carefully  studied  the  reports  of  the  cases  furnished  by  the  vari- 
ous authorities  just  quoted,  and  I  fail  to  find  any  evidence  in 
them  that  the  favorable  results  are  any  different  from  those  oc- 
curring in  similar  cases  when  no  drug  was  used  internally.  It  is 
the  habit  of  those  who  use  the  sulphide  of  calcium,  as  will  be 
seen  by  a  study  of  their  cases,  to  employ  all  the  local  means  that 
are  used  by  surgeons  in  treating  suppurations.  It  is  claimed  that 
the  use  of  the  knife  is  avoided  by  the  abortive  power  of  the  drug. 


1  A  Hand-book  of  Therapeutics,  p.  137.     Tenth  edition.     New  York,  1883. 
*  Archives  of  Otology,  Vol.  XV.,  p.  122. 

3  American  Journal  of  Otology,  Vol.  IV.,  p.  194.     Transactions  of  the  American 
Otological  Society,  Vol.  III.,  Part  II.,  p.  181. 


140  FURUNCLES — CAUSES. 

But  all  of  us  see  many  cases  subside  without  incisions  and  when 
no  internal  medication  is  employed.  Sexton '  says,  "  In  some  in- 
stances I  rely  entirely  on  this  remedy  (calcium  sulphide)  in  the 
treatment  of  inflammation  in  the  ear ;  but  free  incisions  are  in 
some  instances  of  course  not  to  be  omitted." 

The  question  of  the  value  of  internal  medication  is  one  noto- 
riously hard  to  solve  ;  but  certain  it  is,  however,  that  calcium 
sulphide  has  not  yet  obtained  a  firm  hold  upon  the  profession  as 
a  means  of  aborting  or  checking  suppuration.  I  have  not  been 
able  to  satisfy  myself  that  we  as  yet  have  any  specific  for  aural 
inflammations  of  a  suppurative  character. 

We  shall  probably  not  be  done  with  the  case  when  one  fur- 
uncle has  been  evacuated,  and  has  healed ;  for  here,  just  as  in 
other  parts  of  the  body,  one  boil  is  apt  to  follow  another  in  rapid 
succession.  ^ 

I  have  recently  used  a  menthol  solution,  as  advised  by  Ger- 
man writers,  but  I  have  not  found  this  to  be  an  abortive, 
although  it  is  on  the  whole  a  good  application.  If  there  be, 
as  there  perhaps  is,  a  specific  bacillus  to  be  found  in  furun- 
cles, an  agent  to  kill  this  would  be  in  order.  Yet,  I  think, 
there  is  a  soil  prepared  for  it  before  the  germ  becomes  nox- 
ious, here  as  elsewhere.  But  we  should  be  on  the  alert  for  any 
means  of  cutting  short  this  obstinately  recurring  affection.  It 
is  well  to  remember  that  the  old  English  adage,  an  ounce  of 
prevention  is  worth  a  pound  of  cure,  holds  good  in  medicine  as 
well  as  in  other  arts. 

Causes. — This  brings  us  to  consider  the  cause  of  this  affec- 
tion. I  do  not  think  I  ever  saw  a  furuncular  inflammation  of 
the  external  auditory  canal  in  a  patient  who  was  in  other  respects 
in  a  good  physiological  condition.  It  seems  to  be  the  evidence 
of  a  wrong  state  of  the  system  of  some  kind. 

Furuncles  are  very  apt  to  occur  in  anaemic  persons.  I  have 
seen  several  cases  where  they  were  troublesome  after  parturi- 
tion, during  which  the  system  had  been  much  exhausted,  and 
perhaps  the  patient  had  not  been  under  the  most  judicious  man- 
agement as  regards  the  diet.  When  iron  was  administered, 
and  nourishing  diet  substituted  for  slops,  the  boils  ceased  to 
recur. 

Dr.  Lowenburg,"  of  Paris,  examined  furuncles  of  the  auditory 
canal,  prior  to  their  opening,  before  the  pus  formed  in  them 
had  come  into  contact  with  the  atmosphere.  The  pus  freshly 

1  American  Journal  of  Otology,  Vol.  I. 

2  Archives  of  Otology,  Vol.  X.,  p.  220. 


LOWENBURG   ON   FURUNCLES.  141 

obtained  was  cultivated  in  beef  soup  or  diluted  extract  of  beef. 
The  coccus  of  furuncle  was  abundantly  produced  by  these  ex- 
periments. Lowenburg  regards  these  micro-organisms  as  the 
cause  of  furuncular  inflammation.  Micrococci  suspended  in  air 
and  water  get  into  the  canal,  and  passing  into  the  glandular 
structure  set  up  inflammation. 

His  exact  language  is,  "I  think  that  every  furuncle  is  an  in- 
vasion of  a  particular  species  of  microbes,  which  exist  in  the  air 
and  in  water,  and  which  are  multiplied  under  the  influence  of 
the  decomposition  of  certain  substances.  In  consequence  of  some 
circumstances  still  unknown,  these  microzotes  (microzoaires) 
enter  a  pilo-sebaceous  follicle  ;  they  then  fructify  and  excite  the 
characteristic  furuncular  inflammation."  Lowenburg  then  goes 
on  to  show  that  once  having  entered  the  follicle,  the  micrococci 
propagate  themselves  by  what  he  styles  "auto-infection."  The 
parasitic  origin  of  furuncles  is  further  substantiated,  in  Lowen- 
burg's  opinion,  by  the  fact  that  they  chiefly  occur  in  parts  ex- 
posed to  the  air,  the  face,  the  hands,  the  neck.  "The  first  aural 
furuncle,"  he  continues,  "is  found  at  the  entrance  of  the  canal, 
the  succeeding  ones  affect  the  deeper  parts,  and  the  predilection 
of  furuncle  for  those  who  handle  rags." 

The  contagiousness  of  furuncle  is  also  insisted  upon  by  this 
writer,  and  he  records  a  case  where  a  strong  and  healthy  man 
suffered  from  one  in  the  ear  after  his  wife  had  been  affected  by 
one.  '  The  furuncle  in  the  man  was  in  the  left  ear,  in  a  corre- 
sponding situation  to  one  in  the  right  ear  of  the  wife.  Lowen- 
'burg  treats  furuncle  by  an  incision,  under  local  anaesthesia  by 
the  cold  spray.  The  part  is  then  kept  moist  with  solutions  of 
thymic  or  boric  acid.  Weber-Liel  injects  their  tissue  with  a 
solution  of  phenic  acid.  Lowenburg  considers  that  poultices 
favor  the  formation  of  micrococci,  and  that  they  should  not 
therefore  be  used  in  the  treatment  of  furuncles  in  the  ear. 
These  views  of  the  parasitic  origin  of  furuncles  are  entitled  to 
great  respect  in  the  present  condition  of  the  mind  of  the  pro- 
fession, in  regard  to  the  parasitic  origin  of  disease,  yet  I  cannot 
regard  it  as  yet  settled  that  micrococci  are  not  consequences 
rather  than  causes  of  the  diseases  thought  to  be  produced  by 
them.  Certain  it  is,  that  'there  must  be  in  the  general  system 
some  preparation  for  the  invasion  of  these  dangerous  micro- 
organisms, or  in  the  frequency  of  furuncle,  contagion  would  be 
much  more  common.  If  furuncles  be  contagious,  common  ex- 
perience shows  that  they  are  only  so  to  a  limited  degree.  I  have 
never  observed  that  they  passed  through  families.  Lowenburg's 
one  case  seems  to  me  slender  evidence  upon  which  to  base  such 
a  theory.  Then  as  regards  the  value  of  thymic  and  boric  acid 


142  LOWENBURG   ON   FURUNCLES. 

as  antiseptics,  I  am,  from  experience  in  their  use,  and  from  the 
results  of  recent  experiments,  extremely  skeptical.  I  believe 
that  water  is  quite  as  efficacious  as  many  of  the  so-called  anti- 
septics. When  a  question  such  as  the  great  one  of  the  septic 
origin  of  disease  is  being  discussed,  I  believe  that  the  great 
truth  that  must  be  somewhere  in  this  subject  will  be  the  sooner 
brought  out  the  more  frank  and  critical  are  the  analyses  of  the 
theories  and  experiments  that  are  being  constantly -set  forth.1 

1  Congres  Periodique  international  d'otologie.     2e  Session.     Milan,  1880 ;  Trieste, 
Imprimerie  G.  Caprin,  1882. 


CHAPTER  VI. 

PAEASITIC  INFLAMMATION  OF  THE  EXTERNAL  AUDITORY  CANAL 
—SYPHILITIC  ULCERS  AND  CONDYLOMATA— CONTRACTIONS- 
DIPHTHERIA— SARCOMA— CARIES. 

History  of  the  Discovery  of  the  Growth  of  Aspergillus  in  the  External  Auditory  Canal. — 
Varieties  of  Vegetable  Fungi  found  in  the  Ear. — Cases. — Syphilitic  Ulcers  and 
Condylomata. — Narrowing  and  Closure  of  the  Canal. — Diphtheritic  Inflamma- 
tion.— Sarcoma. — Caries  of  the  Canal. 

IT  is  more  than  twenty  years  since  the  profession  became  generally 
aware  of  the  fact  that  vegetable  fungi  were  germinated  m  the 
auditory  canal,  and  that  they  caused  or  aggravated  inflamma- 
tions of  this  part  and  of  the  surface  of  the  membrana  tympani. 
By  the  publications  of  Professor  Schwartze,  of  Halle,  Dr.  Wre- 
den,  of  St.  Petersburg,  and  many  others  whose  names  will  be 
quoted  in  this  chapter,  this  fact  has  now  become  well  known, 
and  has  enabled  us  to  more  clearly  understand  and  more  suc- 
cessfully treat  certain  cases  of  otitis  externa. 

The  history  of  the  growth  of  the  aspergillus  fungus,  as  well 
as  that  of  the  other  vegetable  parasites  that  have  been  found  in 
the  ear,  is  interesting  and  important,  and  a  full  account  of  it 
will,  I  am  sure,  be  welcomed  by  the  reader. 

In  1867,  Schwartze1  reported  a  case  of  inflammation  of  the 
auditory  canal,  in  which  the  aspergillus  fungus  was  found. 
Professor  J.  Vogel  made  the  microscopic  examination  that  set- 
tled the  fact,  and  he  called  Schwartze's  attention  to  two  cases 
which  had  been  previously  reported  ;  one  by  Mayer,  in  Muller's 
Archiv,  p.  401,  1844,  and  one  by  Pacini,  quoted  by  Kuchen- 
meister,  in  his  work  on  "  Parasites,"  published  in  Leipzig  in 
1855.  In  both  these  cases  the  fungus  was  a  species  of  asper- 
gillus. 

Mayer's  case  was  peculiar.  The  fungus  occurred  in  the  ear 
of  a  child,  having  what  he  called  scrofulous  otorrhoea,  and  the 
parasite  was  contained  in  round  and  oval  cysts,  of  the  size  of  a 
•cherry-pit.  The  walls  of  the  cysts  were  fibrous,  filamentous. 


1  Archiv  fur  Ohrenheilkunde,  Bd.  II.,  p.  7. 


144  PARASITIC '  INFLAMMATION. 

white  in  color  externally,  while  within  they  were  hollow,  green- 
ish, and  granular. 

Pacini's  case  was  like  those  that  have  since  been  observed  : 

A  boy  of  fourteen  years  came  from  a  sea-bath,  and  complained  that  water 
remained  in  his  ear.  Itching  and  painful  sensations  ensued,  and  at  last  nearly 
complete  deafness.  In  the  auditory  canal  small  transparent  vesicles  were  seen. 
Two  weeks  after  a  whitish  membrane  was  found  on  the  walls.  It  was  removed 
by  syringing  with  warm  water ;  but  it  soon  returned.  The  microscopic  exami- 
nation revealed  the  presence  of  a  fungus.  The  parasite  was  removed  by  the 
injection  of  a  solution  of  acetate  of  lead,  of  the  strength  of  two  grains  to  the 
ounce  of  water. 

Dr.  Robert  Wreden '  reported  six  cases  of  the  growth  of  the 
aspergillus  fungus  the  year  after  Schwartze's  case  was  pub- 
lished. He  gave  the  name  of  myringomykosis  to  the  disease 
caused  by  the  fungus.  He  subsequently  added  eight  to  these, 
and  published  the  whole,  with  a  very  complete  account  of  the 
appearance  of  the  fungus,  in  a  monograph.3 

Soon  after  the  publication  of  Schwartze's  and  Wreden's  cases 
others  were  reported  by  Orne  Green,*  of  Boston,  0.  J.  Blake, 
Knapp,  and  by  myself4  and  others.  Indeed,  the  occurrence  of 
such  a  fungus  in  an  inflamed  ear  is  now  a  well-recognized  fact, 
for  which  we  are  indebted  to  Schwartze. 

The  literature  of  vegetable  fungus  in  the  human  ear  has  be- 
come very  large  since  the  publication  of  the  cases  of  Schwartze, 
Wreden,  and  of  the  observers  immediately  after  them,  but  in 
very  few  directions  has  it  increased  the  knowledge  given  us  by 
Wreden's  first  brochure. 

Wreden 8  and  Swan  M.  Burnett,8  however,  have  lately  reported  cases  which 
furnish  pretty  strong  evidence  that  the  fungus  known  as  otomyces  purpureus 
may  be  found  in  the  auditory  canal  without  being  a  part  of  the  aspergillus  nigri- 
cans,  or,  as  Wreden  had  thought,  the  highest  form  (most  developed)  of  the  spe- 
cific aural  fungus.  In  other  words,  a  distinct  variety  of  vegetable  fungus  has 
been  found  in  the  ear.  In  Burnett's  case  a  mixture  of  tincture  of  opium,  sweet 
oil,  and  glycerine  had  been  poured  into  the  auditory  canal  to  relieve  the  symp- 
toms of  what  was  called  psoriasis.  The  ear  became  painful  after  this,  and  on 
examination  Dr.  Burnett  found  a  plug  of  dark-red,  quite  consistent  material. 
An  examination  with  the  microscope  showed  this  to  be  a  fungoid  growth.  In 
Wreden's  case  evidences  that  the  growth  was  one  of  the  highest  forms  of  devel- 


1  Archiv  fur  Ohrenheilknnde,  Bd.  III.,  p.  1. 

1  Die  Myringomykosis  aspergillina.     St.  Petersburg. 

3  Transactions  of  the  American  Otological  Society,  1869. 

4  American  Journal  of  the  Medical  Sciences,  January,  1870. 

6  Wreden:  Archives  of  Ophthalmology  and  Otology,  Vol.  IV.,  No.  1. 
•  Archives  of  Otology,  Vol.  X.,  p.  319. 


CAUSES   OF   PAEASITIC   INFLAMMATION.  145 

opment  of  aspergillus  nigricans  were  found,  but  not  so  in  Burnett's.  He  found 
in  his  specimens  at  no  stage  of  their  growth  nothing  but  otomyces  purpureus. 
Professor  Faiiow,  of  Harvard  University,  thought  the  specimen  was  probably 
not  a  variety  of  aspergillus,  as  Wreden  supposed,  in  regard  to  his  case. 

Causes. — In  order  that  we  may  correctly  understand  the  na- 
ture of  parasitic  otitis,  it  should  be  remembered  that  it  is  not  a 
primary  disease,  but  a  consequence  of  a  diffuse  otitis,  which 
may  have  been  of  such  a  mild  character  as  scarcely  to  have  at- 
tracted the  attention  of  a  patient,  especially  if  it  occur  in  one 
who  is  taught  to  believe,  as  most  patients  are,  that  an  aural  dis- 
ease will  "wear  away"  of  itself,  or,  at  any  rate,  that  medical 
assistance  will  be  of  no  avail  for  it. 

The  disease,  that  is  the  formation  and  development  of  a  vege- 
table fungous  growth,  may  result  from  an  eczema,  or,  as  in  Bur- 
nett's case,  just  quoted,  from  a  psoriasis,  or  probably  from  any 
form  of  inflammation  of  the  canal,  especially  if  oils  have  been 
dropped  into  it.  I  have  not  yet  seen  a  case  of  otitis  parasitica 
in  which  I  thought  there  was  any  evidence  to  show  that  the  ear 
was  sound  just  before  the  growth  occurred.  The  soil  must  first 
be  prepared  by  a  loosening  of  the  epidermis  before  the  fungus 
will  grow. 

The  origin  of  the  disease  may  generally  be  traced  back  to  an 
inflammatory  affection  of  the  canal,  one  that  has  softened  the 
tissues.  Added  to  this,  oils,  generally  the  common  sweet  oil, 
have  been  used  to  combat  the  inflammation.  Given  these  two 
factors,  the  inflammatory  basis  and  the  oils,  and  the  propagation 
of  the  aspergillus  fungus  may  be  pretty  accurately  predicted. 
One  of  the  best  reasons  against  the  use  of  oils  in  the  canal  is 
their  liability  to  cause  the  growth  of  a  fungus. 

The  fungus  is  actually  a  mould,  such  as  clings  to  damp  walls 
and  adheres  to  bread  that  is  not  kept  thoroughly  dry.  As  we 
should  expect,  the  habits  of  the  Russians,  living  as  they  are 
almost  compelled  to,  in  badly  ventilated  rooms  during  the  long 
winter,  are  very  favorable  to  the  production  of  aspergillus. 

There  is  hardly  a  doubt  that  these  cases  of  vegetable  fungous 
growths  in  the  ear  were  formerly  mistaken  for  impacted  ceru- 
men or  eczema,  and  otitis  externa  diff  usa.  Since  my  attention 
has  been  called  to  the  subject,  I  recall  two  cases  of  very  obstinate 
inflammation  of  the  auditory  canal,  which  I  now  believe  were 
cases  of  the  growth  of  vegetable  parasites  in  the  part.  It  is  an 
interesting  fact,  that  they  both  recovered  from  the  affection 
without  any  use  of  the  specific  parasiticides. 

The  wax  is  thought  by  C.  H.  Burnett  to  be  a  protection  against 
aspergillus,  but  I  regard  it  rather  as  an  incident  in  the  formation 

10 


146  PARASITIC    INFLAMMATION. 

of  the  fungus,  for  I  think  it  is  pretty  well  established  that  ceru- 
men never  becomes  hardened  or  impacted  in  a  healthy  auditory 
canal. 

It  is  not  very  uncommon  to  find  a  growth  of  aspergillus  at 
the  bottom  and  on  the  sides  of  an  auditory  canal  that  was 
packed  with  cerumen.  The  disease  is  apparently  much  more 
rare  in  England  than  in  this  country,  for  an  aural  surgeon  in 
large  practice  in  London  had  not  even  seen  a  specimen  of  asper- 
gillus that  had  been  found  in  an  ear  until  I  sent  him  a  slide 
containing  one,  taken  from  one  of  my  cases. 

Symptoms. — The  subjective  symptoms  of  the  growth  of  a 
vegetable  fungus  in  the  ear  are  very  similar  to  those  from  in- 
spissated cerumen.  There  is  a  sensation  of  fulness  in  the  ear, 
with  tinnitus  aurium,  vertigo,  impairment  of  hearing,  and  pain. 

As  is  well  known,  pain  is  not  a  common  symptom  of  inspis- 
sated cerumen,  although  it  does  occur.  Pain  is,  however,  usu- 
ally one  of  the  symptoms  of  otitis  parasitica.  It  is  not  usually, 
however,  the  severe  pain  of  a  furuncle,  or  of  acute  catarrh  of 
the  middle  ear,  but  it  is  a  dull,  heavy  sensation  in  the  ear. 

The  objective  symptoms  consist  in  the  adherence  to  the  walls 
of  the  canal  and  to  the  outer  surface  of  the  membrana  tympani 
of  whitish,  or  blackish,  or  even  reddish  flakes,  that  may  be  read- 
ily mistaken  for  simple  epidermis  or  hard  wax.  Sometimes  these 
flakes  or  casts  block  up  the  whole  passage.  They  cannot  be  re- 
moved by  a  syringe  ;  but  the  angular  forceps,  which  should  only 
be  used  under  a  good  illumination  by  means  of  the  otoscope,  are 
required  to  detach  them.  When  the  casts  are  removed  the  tissue 
beneath  is  found  to  be  reddened  and  tender,  and  in  a  very  few 
hours  the  growth  will  be  found  to  be  reproduced. 

The  microscope  must  be  called  in  to  make  the  diagnosis  cer- 
tain. The  appearance  of  the  growth,  as  seen  by  the  aid  of  this 
instrument,  will  soon  be  detailed.  The  practitioner  who  has  once 
carefully  observed  the  objective  and  macroscopic  evidences  of  a 
vegetable  fungus,  will,  however,  not  be  apt  to  fail  to  recognize 
it  in  a  subsequent  case  without  a  microscope. 

The  varieties  of  vegetable  parasites  that  may  be  found  in  the 
ear,  and  which  there  cause  or  increase  inflammation,  are 

C  flavus,  III.  Graphium  pencilloides. 

I.  Aspergillus  <  glaucus,  IV.  Trichothecium  roseum. 

(  nigricans.  V.  Otomyces  purpureus. 
II.  Penicillium  glaucum. 

The  aspergillus  fungus,  which,  in  one  of  its  varieties,  is  the 
parasite  most  commonly  found  in  the  ear,  seems  to  have  a  pecu- 


ASPEKGILLTJS.  147 

liar  affinity  for  a  diseased  auditory  canal  and  membrana  tym- 
pani,  and  to  be  found  almost  exclusively  on  this  part  of  the  body. 
Dr.  William  H.  Draper,  of  this  city,  has,  however,  observed  one 
case  of  the  growth  of  the  aspergillus  fungus  on  the  inner  side  of 
the  thigh,  and  it  afterward  appeared  in  the  auditory  canal. 
Wreden  was  not  able  to  find  any  penicillium  fungus  in  his  cases, 
but  Blake '  reports  a  case  in  which,  on  the  second  attack  of  otitis 
parasitica,  specimens  of  bastard  penicillium  were  found. 

Dr.  Hassenstein,3  of  Gotha,  has  observed  one  case  in  which  a 
patient  suffering  from  the  usual  symptoms  of  aural  catarrh  was 
found  to  have  a  yellowish-green  secretion  upon  the  membrana 
tympani.  This  secretion  continued  for  some  ten  days,  in  spite 
of  treatment,  and  there  was  considerable  redness,  swelling,  and 
pain  in  the  auditory  canal  and  drum-head. 


FIG.  47. — Aspergillus  Nigricans  (220  diameters),  a,  Mycelium  fibre  ;  6,  fruit-bearing 
fibre  ;  c,  naked  sporangium  ;  d,  sporangium  covered  with  basidia  only  ;  e,  more  mature  spo- 
rangium ;  i,  spores  in  a  state  of  germination. 

This  secretion  was  found  to  contain  three  varieties  of  vege- 
table fungi,  as  an  examination  by  Professor  Hallier,  of  Jena, 
showed :  1.  Aspergillus  glaucus.  2.  Stemphylium,  which  was 
very  like  stemphylium  polomorphum  belonging  to  the  asper- 
gillus. 3.  Graphium  pencilloides.  Dr.  Hallier  was  unable  to  say 
whether  the  second  variety  sprang  directly  from  the  aspergillus 
or  not.  The  graphium  pencilloides,  of  which  an  accurate  botan- 
ical description  is  given  in  the  article  from  which  I  am  quoting, 
occurs  in  nature  on  wood,  especially  on  elder-wood. 

1  Transactions  of  the  American  Otological  Society,  fourth  year,  1871. 

2  Archiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  164. 


148  PARASITIC   INFLAMMATION. 

Dr.  F.  Steudener,1  of  Halle,  describes  another  form  of  fungus 
which  occurs  in  the  ear,  Trichothecium  roseum.  The  evidence 
on  this  point  is  not  quite  conclusive,  however,  for  Professor  de 
Barry,  to  whom  Dr.  S.  showed  the  specimen,  said  it  resembled 
this  fungus,  although  it  could  not  be  thoroughly  examined,  the 
specimen  having  been  injured.  Dr.  Steudener  then  cultivated 
the  actual  trichothecium  fungus  upon  some  epidermis,  and  in- 
asmuch as  the  spores  and  mycelium  resembled  those  in  the 
fungus  removed  from  the  ear,  he  thought  himself  justified  in 
assuming  that  the  latter  were  actually  those  of  the  trichothecium 
roseum.  The  evidence  is  therefore  not  quite  positive  as  to  the 
nature  of  the  fungus. 

The  different  varieties  of  the  aspergillus  fungus  are  by  far  the 
most  common  kinds  of  vegetable  parasites  that  have  been  found 
in  the  ear,  although,  now  that  attention  has  been  turned  to  this 
subject,  others  have  been  found.  ^ 


FIG.  48.— Aspergillus  Flavescens  (220  diameters),  a,  Mycelium  fibre;  &,  fruit-bearing  fibre; 
c,  sporangium-bearing  spores  upon  the  basidia ;  g,  basidia,  showing  constriction  preparatory 
to  the  separation  of  spores ;  k,  epithelium. 

The  first  two  of  the  accompanying  drawings  of  the  aspergillus 
were  made  by  my  friend,  the  late  Dr.  William  B.  Lewis,*  for  an 
article  by  myself  upon  the  subject,  from  specimens  of  cases 
occurring  in  my  practice.  The  third  engraving  (Fig.  48)  repre- 
sents another  specimen  from  the  same  source,  which  was  drawn 
by  Dr.  Charles  S.  Bull.  Dr.  Lewis  describes  the  fungus  as  of 
three  essential  parts : 

First,  the  mycelium,  a  dense  network  or  pseudo-membrane  of 
delicate  fibres,  which  form  the  groundwork  or  roots,  as  it  were, 
from  which  the  second  part,  or  fructifying  portion  (fertile 
hyphen),  arises  perpendicularly ;  and  third,  the  free  spores,  which 
lie  thickly  strewn  upon  and  in  the  mycelium. 

1  Archiv  fur  Ohrenheilkunde,  Bd.  V.,  p.  163. 

2  American  Journal  of  the  Medical  Sciences,  Vol.  LIX.,  1870,  p.  105. 


ASPERGILLTJS. 


149 


The  physiological  relation  of  the  fruitful  fibres  to  the  mycelium  is  not  shown 
in  the  accompanying  cuts,  but  may  be  at  once  made  clear  by  examining  a  portion 
of  common  mould  with  low  power. 

The  fibres  of  the  pseudo-membrane  are  unfruitful,  branched,  straight,  or 
curved,  and  frequently  somewhat  swollen  at  the  joints.  In  the  broader  fibres 
transverse  cell-walls  are  distinguished,  and  all,  broad  and  narrow,  contain  faintly 
granular  plasma.  The  breadth  of  the  mycelium  fibres  was  from  0.00015  to  0.0002 
of  an  inch  (0.0038  to  0.005  of  a  millimetre). 


PIG.  49.— Specimefc  of  the  Spores  and  fully  developed  Growth  of  the  Aspergillus  Flavescens. 

(Case  III.) 

In  the  fruit-bearing  portion  are  found  the  changes  in  form  which  establish 
the  varieties.  It  consists  of  a  filament,  which,  especially  in  the  aspergillus 
nigricans,  is  stouter  than  those  of  the  mycelium,  bearing  upon  its  summit  an 
enlargement,  the  receptacle  or  sporangium. 

Those  who  are  interested  in  a  fuller  botanical  description  of  the  fungus  will 
find  it  in  the  journal  from  which  I  have  quoted,  as  given  by  Dr.  Lewis,  in  an 
article  furnished  by  Dr.  L.  and  myself,  and  in  Wreden's  monograph. 


150 


PENICILLIUM — OTOMYCES  PURPUREUS. 


FIG.  50. — Penicillium  (after 
Blake). 


In  Dr.  Blake's  case,  which  has  been  alluded  to,  a  portion  of 
the  specimen  was  planted  upon  lemon-peel,  placed  in  a  closed 
glass  vessel,  at  a  constant  temperature  of  80°  F.,  when  it  gave, 
at  the  end  of  the  third  day,  a  well-developed  growth  of  the  Lep- 
tothrix  form  of  Penicillium. 

The  specimen  represented  in  the  accompanying  wood-cut 
exhibited  a  mycelium  and  fully  devel- 
oped sporangia  (a).  The  spores,  of 
which  a  collection  is  represented  at  6, 
were  of  a  brown  color  and  oval  outline, 
of  about  the  same  size  as  the  spores  of 
Aspergillus  nigricans.  Under  a  mag- 
nifying power  of  300,  some  of  these 
spores  showed  a  double  outline.  Min- 
gled with  this  growth  there  was  a  close  network  of  very  fine 
mycelium. 

Treatment.  —  The  treatment  of  otitis  parasitica  is  exceed- 
ingly simple,  but  it  is  often  very  tedious,  and  the  practitioner 
must  not  expect  that  all  the 
aural  "symptoms  will  be  re- 
lieved when  the  vegetable  fun- 
gus has  ceased  to  appear.  We 
may  only  expect  to  relieve  the 
most  troublesome  symptoms, 
pain,  vertigo,  and  impairment 
of  hearing,  by  the  destruction 
of  the  parasite.  The  inflam- 
mation will  continue,  in  some 
cases,  long  after  the  micro- 
scope has  failed  to  find  any 
traces  of  aspergillus  in  the 
auditory  canal. 

But  the  loosened  epidermis 
and  the  flakes  of  mould  should 
be  carefully  removed  every 
day  by  means  of  the  forceps 
and  syringe,  the  ear  being  well  illuminated  while  the  former  is 
used,  and  the  canal  frequently  douched  with  warm  water  by 
means  of  the  fountain  syringe  or  the  Fayette  douche.  I  am  in 
the  habit  of  pencilling  the  canal  with  nitrate  of  silver  in  strong 
solutions,  after  the  cleansing  process  is  over,  for  the  purpose 
of  destroying  the  fungus,  and  subduing  the  inflammation  of  the 
integument.  At  the  same  time,  I  treat  any  affection  of  the 
middle  ear,  that  may  co-exist  with  that  of  the  canal,  by  the  ap- 
propriate means. 


PIG.  51.— Otomyces  Purpureus  (S.  M.  Bur- 
nett), a,  a,  a,  a,  Younger  asci ;  b,  b,  b,  mature 
asci  ;  c,  free  spores  ;  d,  mycelium. 


PARASITIC   INFLAMMATION.  151 

Dr.  Wreden  gives  a  long  list  of  agents  which  he  believes  to 
be  useful  as  parasiticides.  He  mentions,  among  others,  alcohol, 
bichloride  of  mercury,  acetate  of  lead,  tincture  of  iodine,  and 
carbolic  acid.  He  prefers  the  hypochlorate  of  lime,  which  he 
recommends  to  be  used  in  the  strength  of  one  to  two  grains  to 
the  ounce  of  water.  The  salt  must  be  freshly  dissolved  in  water 
at  each  application.  Fowler's  solution  ranks  next  to  the  lime 
as  a  parasiticide,  according  to  Wreden.  Solutions  of  tannic 
acid,  gr.  x.  ad.  §  j.,  are  used  by  some  authorities. 

Drs.  Orne  Green,  of  Boston,  and  Knapp,  of  this  city,  concur 
with  me  in  believing  that  a  thorough  use  of  warm  water  is  -the 
only  parasiticide  generally  necessary. 

The  bichloride  of  mercury  in  solution,  gr.  j.  ad.  f  j.,  and  pure 
alcohol  are  certainly  efficient  in  the  destruction  of  the  fungus. 
Either  may  be  dropped  into  the  ear  ;  alcohol  causes  some  burn- 
ing, but  the  pain  is  not  usually  severe,  nor  does  it  last  long. 

According  to  Siebenmann,1  Kramer  described  a  specimen  of 
aspergillus  niger  with  great  accuracy  in  1859.  He  does  not  give 
the  reference  to  Kramer's  writings,  and  I  have  not  been  able  to 
find  it.  Kramer  found  the  fungus  in  the  form  of  a  white  mem- 
brane upon  the  membrana  tympani.  Its  inner  surface  was  cov- 
ered by  black  specks  supported  by  pedicles.  The  membrane  was 
the  mycelium,  the  black  points  the  condiophores.  Kramer  cured 
his  case  after  many  relapses  by  the  use  of  acetate  of  lead. 

In  the  treatment  of  parasitic  otitis  it  is  wise  to  observe  all  the 
antiseptic  precautions  suggested  by  Lowenburg  :  1.  Do  not  use 
oils  or  fats.  2.  Use  alcoholic  solutions,  or  solutions  containing 
as  little  alcohol  as  possible.  3.  Dilute  these  solutions  with  boil- 
ing water  before  using  them.  4.  Heat  all  instruments — that  is, 
wash  them  in  boiling  water — used  in  treating  aspergillus. a 

The  following  cases  will  furnish  a  commentary  on  what  has 
been  said,  and  perhaps  illustrate  the  nature  of  the  affection 
better  than  any  more  extended  remarks.  The.  first  two  have 
already  been  published,3  but  the  third  has  never  before  been 
printed. 

CASES  OF  ASPERGILLUS. 

CASE  I. — I  was  consulted,  June  30,  1869,  by  J.  F.  B ,  a  gentleman  set.  24, 

in  regard  to  pain  and  impairment  of  hearing  in  the  left  ear.  He  stated  that 
about  a  year  before  he  had  experienced  a  sense  of  fulness  in  the  ear,  as  if  it 
were  "  stopped  up,"  and  that,  at  the  same  time,  there  was  considerable  tinnitus 
aurium.  He  consulted  a  physician,  who  diagnosticated  inspissated  cerumen, 


1  Archives  of  Otology,  Vol.  XV.,  p.  189. 

*Loc.  cit.,  p.  196. 

3  American  Journal  of  the  Medical  Sciences,  loc.  cit. 


152  ASPERGILLUS — CASES. 

and  removed  a  large  quantity  of  what  seemed  to  be  ear-wax  from  the  canal. 
The  relief  afforded  was  of  short  duration,  for  the  ear  soon  filled  up.  From  that 
time  to  the  present  the  patient  has  been  in  the  habit  of  syringing  the  ear,  and 
at  times  masses  of  some  foreign  substance  were  removed  by  this  process.  Of 
late  he  has  noticed  black  particles  strewn  in  the  substance  removed,  which  he 
thinks  are  due  to  the  entrance  of  dust  from  the  smoke-pipe  of  a  steamer  during 
a  recent  voyage  from  Europe.  The  patient  now  experiences  very  considerable 
pain  in  the  ear,  and  it  is  the  occurrence  of  this  new  symptom  which  has  led  him 
to  consult  me.  The  other  symptoms — the  sensation  of  fulness,  tinnitus  aurium, 
and  impaired  hearing,  continue.  Patient's  general  health  is  good,  though  he  is 
very  subject  to  naso-pharyngeal  catarrh. 

On  examination,  a  watch  which  is  usually  heard  at  least  thirty  inches  from 
the  auricle  is  only  heard  one  and  a  half  inch,  and  the  auditory  canal  is  filled 
with  a  lardaceous  mass,  punctated  by  minute  black  spots.  This  mass  was  very 
adherent  to  the  walls  of  the  canal,  and  could  not  be  thoroughly  removed  by 
syringing,  but  required  the  use  of  the  angular  forceps,  under  a  good  illumination 
by  means  of  Troltsch's  otoscope  and  ordinary  daylight.  The  surface  beneath 
this  mass,  which  peeled  off  from  the  canal,  was  red  and  very  sensitive.  After 
the  removal  of  the  foreign  substance,  a  minute  perforation  of  the  membrana 
tympani  was  found  situated  in  the  anterior  and  inferior  quadrant.  There  was  no 
true  suppuration,  but  mucus  alone  bubbled  out  from  the  opening  during  the  in- 
flation of  the  Eustachian  tube.  The  Eustachian  tube  was  shown  to  be  perme- 
able by  Politzer's  method,  but  there  was  very  little  sensation  experienced  in  the 
ear  when  the  air  was  forced  in. 

On  the  removal  of  the  collection,  the  patient  experienced  immediate  relief 
from  the  pain  and  tinnitus  aurium,  but  the  hearing  was  not  very  much  improved. 
The  diagnosis  catarrh  of  the  middle  ear  was  made,  while  an  exact  definition  of  the 
state  of  things  in  the  canal  was  delayed.  Portions  of  the  lardaceous,  flaky  sub- 
stance removed  from  the  canal  were  placed  in  glycerine. 

He  was  ordered  to'use  injections  of  wai*m  water,  by  means  of  Clark's  aural 
douche,  several  times  daily,  and  to  drop  in  a  solution  of  zinc,  sulph.,  gr.  ij.  ad. 
aqua  5j->  twice  a  day.  The  Eustachian  catheter  was  used,  and  air  injected 
through  it  into  the  cavity  of  the  tympanum. 

It  was  some  days  before  the  entire  collection  was  fully  removed,  and  in  spots 
where  it  had  been  separated  and  taken  out  it  was  renewed  very  rapidly,  and 
each  time  reproduced- the  symptoms  of  pain  and  fulness.  A  weak  solution  of 
carbolic  acid  was  then  used ;  but  it  caused  very  great  irritation,  and  inflamma- 
tion was  set  up,  which  lasted  many  days.  This  was  treated  by  the  use  of  warm 
water,  through  the  douche.  "When  it  had  subsided,  the.  lardaceous  masses  were 
removed  by  the  forceps,  and  in  some  instances  casts  of  the  membrana  tympani 
came  away,  although  the  walls  of  the  canal  showed  the  most  disposition  to  a  re- 
production of  the  growth. 

July  27th,  the  opening  in  the  membrana  tympani  had  healed,  and  the  hearing 
so  much  improved  that  the  watch  was  heard  six  inches,  and  the  symptoms  com- 
pletely relieved.  There  was  still  a  slight  tendency  to  the  growth  of  the  fungus, 
as  it  proved  to  be,  on  the  posterior  wall  of  the  canal.  The  membrana  tympani 
was  lustreless  and  rigid,  the  handle  of  the  malleus  distinct,  but  there  was  no 
light  spot.  From  the  1st  of  August  I  did  not  again  see  my  patient  until  October 
18th.  Meanwhile  he  had  used  the  aural  douche  daily,  and  the  growth  had  not 
returned  ;  but  the  catarrhal  inflammation  of  the  middle  ear  had  not  been  materi- 


ASPERGILLUS — CASES.  153 

ally  benefited,  as  shown  by  the  rigidity  of  the  membrana  tympani  and  the  inv 
pairment  of  hearing.  The  membrane  is  now  (November  19th)  somewhat  translu- 
cent, and  the  patient  is  being  treated,  with  benefit,  by  means  of  the  injection  of 
air,  the  use  of  a  gargle,  etc.,  for  the  middle-ear  affection. 

The  flakes,  preserved  in  glycerine,  were  examined  by  my  friend  Dr.  0.  E. 
Hackley  and  myself  under  the  microscope,  and  Dr.  Hackley  believed  them  to 
exhibit  specimens  of  Aspergillus  nigricans.  At  a  later  date  Dr.  Wm.  B.  Lewis 
very  kindly  made  a  thorough  examination,  and  confirmed  Dr.  Hackley's  opinion. 
In  this  case  it  is  clearly  evident  that  the  growth  of  the  fungus  was  secondary 
to  the  inflammation  of  the  middle  ear,  for  the  patient  never  fully  recovered  his 
hearing  power. 

CASE  II. — September  28,  1869,  I  was  consulted  by  Mr.  S ,  set.  51,  on  ac- 
count of  impaired  hearing,  vertigo,  pain  in  the  ears,  and  tinnitus  aurium.  Ver- 
tigo was  the  symptom  upon  which  the  patient  laid  the  most  stress,  and  of  which 
he  was  most  anxious  to  be  relieved.  He  said  that  he  was  so  dizzy  whenever  he 
attempted  to  walk  about,  as  to  be  unable  to  attend  to  his  ordinary  business. 
His  condition  in  other  respects  was  excellent.  The  patient  also  stated  he  had 
heard  perfectly  well  until  two  months  since,  when  he  was  attacked  with  the 
aural  symptoms  narrated  above,  which  had  been  aggravated  since  their  incep- 
tion. He  had  been  treated  by  the  instillation  of  oils,  and  so  on.  He  could  hear 
my  watch  about  one  inch  on  the  right  side,  and  not  at  all  on  the  other.  Both 
auditory  canals  were  found  filled  with  a  tenacious  material,  which  could  only 
be  removed  by  the  forceps.  It  was  several  days  before  I  could  completely  re- 
move the  firmly  adherent  coating  of  the  canal  and  membrana  tympani. 

The  morbid  product  was  immediately  examined  by  Dr.  Lewis,  and  found  to 
be  a  specimen  of  the  Aspergillus  flavescens.  Its  removal  gave  the  patient  great 
relief ;  but  on  the  reappearance  of  the  growth,  which  was  in  two  or  three  days 
after  its  thorough  removal,  the  vertigo  and  tinnitus  returned.  The  membrana 
tympani  was  intact,  but  lustreless  and  rigid.  The  Eustachian  tubes  opened 
sluggishly,  and  there  was  all  the  evidence  of  aural  catarrh,  besides  the  affection 
of  the  canal  and  of  the  outer  layer  of  the  membrane  of  the  tympanum.  The 
free  use  of  warm  water,  with  an  astringent,  finally  subdued  the  morbid  process 
in  the  canal,  so  that  the  patient  was  able  to  make  a  journey  to  the  South.  When 
he  left  my  care,  October  18th,  the  auditory  canals  were  entirely  free  from  ab- 
normal secretion,  the  hearing  was  improved,  so  that  the  watch  was  heard  from 
five  to  six  inches  on  the  right  side,  and  from  one  to  two  on  the  left.  The  dizzi- 
ness was  entirely  gone,  and  the  tinnitus  ceased  to  be  annoying.  The  catarrh  of 
the  middle  ear,  as  shown  by  rigidity  of  the  membrana  tympani,  sluggish  action 
of  the  tubes,  and  impairment  of  hearing,  still  continued.  I  saw  this  patient 
about  a  year  afterward,  and  he  was  entirely  well,  his  ears  having  returned  to  a 
normal  condition. 

CASE  III.— Lt.  L .  fet.  30,  U.  S.  N.— December  2,  1872.— Since  a  child, 

has  been  more  or  less  deaf  in  right  ear,  owing  to  a  series  of  abscesses.  This 
impairment  of  hearing  was  increased  by  his  service  near  the  frequent  explosion 
of  cannon.  About  a  year  ago  he  had  an  abscess  in  left  ear  (probably  in  audi- 
tory canal),  with  considerable  purulent  discharge  having  an  offensive  odor.  For 
about  two  weeks  he  has  had  a  series  of  abscesses  in  the  left  ear,  with  consider- 
able discharge  of  black  material. 


154  ASPERGILLUS — SYPHILITIC    ULCERS. 

Hearing  distance,  B.  -&-,  L.  &. 

The  tuning-fork  was  heard  more  distinctly  in  the  right  ear  when  the  handle 
was  placed  on  the  forehead  or  teeth.  The  pharynx  is  granular. 

The  right  membrana  tympani  is  very  much  sunken  and  is  opaque. 

The  auditory  canal  of  that  side  contains  numerous  scales  of  epidermis  strewn 
with  black  spots. 

The  left  canal  is  full  of  pus,  and  the  membrana  tympani  is  perforated. 

The  microscopic  examination  showed  the  presence  of  the  aspergillus  nigri- 
cans  in  both  auditory  canals. 

The  patient's  general  condition  was  excellent,  except,  as  is  the  case  with 
most  aural  patients,  he  was  somewhat  despondent  on  account  of  the  loss  of 
hearing. 

The  diagnosis  of  chronic  suppurative  inflammation  of  the  middle  ear,  with 
aspergillus  growth,  was  made  as  regards  the  left  ear.  In  the  right,  there  was 
chronic  non-suppurative  inflammation  with  the  same  fungus  growth  in  the  audi- 
tory canal. 

The  patient  was  seen  nearly  every  day  until  December  24th,  and  treated  by 
the  use  of  leeches,  the  syringe  and  warm  water,  with  the  subsequent  applica- 
tion of  nitrate  of  silver,  gr.  xl.  ad.  §  j.,  brushed  over  the  canal  and  drum-head. 
The  patient  also  caused  his  ears  to  be  syringed  at  home,  and  instilled  a  solution 
of  sulphate  of  zinc,  two  grains  to  the  ounce,  inio  the  ears.  The  Eustachian 
catheter  and  Politzer's  method  were  used  to  force  air  into  the  middle  ears,  and 
the  patient  used  a  gargle  of  chlorate  of  potash. 

The  aspergillus  fungus  disappeared  in  a  few  days,  but  the  affection  of  the 
middle  ear  and  canal  lasted  much  longer. 

On  the  24th  of  December,  however,  just  twenty-two  days  after  he  came  un- 
der treatment,  Lt.  L was  discharged,  with  hearing  distance  for  wateh, 

Q  I  -I  O 

B.  jjjT,    Ij'-jTv      At  sixteen  feet  distant  he  could  hear  and  carry  on  a  conversa- 

^O  4O  , 

tion  in  the  ordinary  tone,  with  his  face  away  from  the  speaker.  The  left  canal 
still  continued  to  swell,  and  the  epidermis  to  scale  off.  The  patient  had  eczema 
of  the  scalp  and  auricle.  Some  weeks  after  he  was  said  to  be  still  improving. 

Cases  of  the  formation  of  vegetable  fungi  in  inflamed  audi- 
tory canals  are  now  matters  of  such  every-day  occurrence, 
among  those  that  see  much  of  aural  disease,  that  they  are  not 
cases  of  great  interest.  Nevertheless  they  are  of  considerable 
importance.  Their  origin  should  be  understood  and  their  occur- 
rence not  overlooked. 


SYPHILITIC  ULCERS.— CONDYLOMATA. 

In  the  course  of  secondary  syphilis  ulcers  and  condylomata 
may  occur  in  the  auditory  canal,  just  as  syphilitic  eruptions  may 
occur  on  the  auricle  and  on  other  parts  of  the  general  integu- 
ment. They  are,  however,  somewhat  rare.  The  manifestations 
of  syphilis  in  other  parts  of  the  body,  with  the  characteristic  ap- 
pearance, and  the  absence  of  itching  sensations,  will  usually 


NARROWING   OF   CANAL — DIPHTHERITIC   INFLAMMATION.      155 

make  the  diagnosis  quite  clear.  While  it  is  true,  as  Schwartze 
intimates,1  that  it  is  sometimes  difficult  to  decide  whether  a  given 
case  of  granulations  in  the  auditory  canal  depends  upon  a  syphi- 
litic dyscrasia  or  not,  since  the  anatomical  constitution  of  the 
tumors  are  the  same  whether  syphilitic  or  not,  yet  this  is  not 
usually  the  case.  There  is  no  more  difficulty  in  making  a  diag- 
nosis here,  than  in  determining  whether  a  case  of  iritis  is  or  is 
not  caused  by  the  poison  of  syphilis.  Of  course  it  is  important  to 
decide  as  to  the  existence  of  syphilis  in  a  person  suffering  from 
ulcers  or  granulations  of  the  auditory  canal,  for  if  syphilis  be 
not  present,  local  treatment  will  often  be  all  that  is  required.  If, 
however,  the  ulcers  be  the  manifestations  of  the  venereal  poison, 
or  be  modified  by  it,  the  use  of  mercury  and  iodide  of  potassium 
will  be  essential. 


NARROWING  AND  CLOSURE  OF  THE  CANAL. 

Of  congenital  closure  of  the  auditory  canal  in  connection 
with  absence  or  deformity  of  the  auricle,  I  have  already  spoken. 
There  remains  to  be  mentioned,  -however,  a  narrowing,  or  even 
closure  of  this  passage,  which  sometimes  occurs  as  a  result  of  a 
neglected  inflammation — usually  if  not  always  of  an  ulcerative 
character.  It  will  perhaps  be  better  to  discuss  the  whole  subject 
of  contractions  of  the  canal  under  the  head  of  bony  growths, 
exostosis  and  hyperostosis,  these  being  usually  the  result  of  in- 
flammatory action.  I  will  therefore  refer  the  reader  to  the 
chapter  upon  the  results  of  chronic  suppuration  for  a  considera- 
tion of  the  subject  of  closure  of  the  canal  as  a  result  of  inflam- 
mation. 

DIPHTHERITIC  INFLAMMATION. 

That  diphtheria  of  the  middle  ear  may  and  does  occur,  has 
been  shown  by  numerous  observers.  I  have  seen  it  in  one  case 
where  no  antecedent  inflammation  of  the  middle  ear  existed.  A 
suppurative  inflammation  of  this  part  may  readily  take  on  a 
diphtheritic  form  in  case  the  patient  be  attacked  with  the  consti- 
tutional disease.  I  have  never  seen  diphtheria  of  the  canal,  but, 
as  we  should  imagine,  it  is  sometimes  developed  on  the  excori- 
ated parts  of  an  auditory  canal  already  suffering  from  simple 
inflammation  during  an  epidemic  of  diphtheria. 

1  Archiv  far  Ohrenheilkunde,  B.  IV.,  p.  263. 


156  SARCOMA — CAEIES. 


SARCOMA  OF  THE  CANAL. 

I  have  seen  one  case  of  tumor  in  the  canal,  which  was  said 
TJV  a  competent  microscopist,  Dr.  Welch,  to  be  a  round-celled 
sarcoma.  The  case  is  elsewhere  reported  in  full  by  Dr.  Buck,1 
who  sent  it  to  me  for  consultation.  The  patient  was  a  girl  of 
fourteen.  The  first  intimation  that  she  had  of  trouble  was  a  ful- 
ness and  pain  in  the  part.  The  canal  was  found  to  be  filled  up 
near  the  meatus  by  a  firm  fleshy  mass.  It  sprung  by  a  broad 
base  from  the  upper  and  posterior  wall  of  the  bony  part  of  the 
canal.  The  child  was  healthy  in  all  other  respects.  Besides  the 
marks  of  sarcoma  Dr.  Welch  found  osseous  tissue  in  the  centre 
''with  wide  medullary  spaces  in  which  the  tissue  is  rich  in  cells 
and  fibrillated."  Dr.  Welch  pronounced  the  tumor  to  be  osteo- 
sarcoma,  taking  its  origin  most  probably  from  the  periosteum. 
Dr.  Delafield  confirmed  Dr.  Welch's  opinion,  and  he  added  if  the 
bone  be  not  involved  and  the  tumor  can  be  completely  removed, 
the  prognosis  is  not  very  bad.  Dr.  Buck,  Dr.  Weir,  and  myself 
agreed  that  the  tumor  should  be  completely  removed,  which  was 
done  by  Dr.  Buck,  under  ether,  by  means  of  knives  and  a  sharp- 
€dged  steel  scoop.  A  zone  of  skin,  apparently  healthy,  surround- 
ing the  entire  base  was  also  removed.  The  growth  sprung  from 
the  periosteum.  The  exposed  bone  was  scraped  and  a  solution 
of  chloride  of  zinc,  forty  grains  to  the  ounce  of  water  was 
painted  over  the  exposed  surface.  The  patient,  who  was  of 
strong  and  healthy  parents,  did  perfectly  well,  and  remains  well 
four  years  after  the  operation.  Dr.  Buck,  in  closing  his  account 
of  this  remarkable  case,  states  that  the  maternal  grandmother 
died  of  some  uterine  disease  which  may  have  been  cancerous  in 
its  nature,  and  that  a  grand-aunt  and  two  second  cousins  suf- 
fered from  cancer. 


CARIES  OF  THE  AUDITORY  CANAL. 

Death  of  the  bony  wall  of  the  auditory  canal  with  no  disease 
of  the  tympanic  cavity,  is  not  a  common  affection,  but  it  may  oc- 
cur. I  have  under  my  care,  while  writing  this,  a  gentleman  of 
more  than  eighty  years  of  age,  who,  while  not  suffering  from 
any  other  form  of  aur"al  disease,  has  an  affection  of  this  kind. 
Just  at  the  junction  of  the  osseous  with  the  cartilaginous  canal, 
anteriorly,  the  bone  is  diseased,  and  my  associate,  Dr.  Emerson, 
has  removed  a  small  piece  of  dead  bone  from  it.  The  disease  be- 

1  Diseases  of  the  Ear,  p.  121. 


CAEIES    OF   CANAL.  157 

gan  as  a  severe  local  inflammation  of  the  canal  furuncle,  for 
which  the  patient  was  treated  by  his  physician  in  Newport,  Dr. 
Rankin.  The  symptoms,  which  wrere  severe,  abated,  and  when 
Dr.  Rankin  referred  him  to  me,  at  the  end  of  the  summer,  there 
was  some  tenderness  at  the  junction  of  the  auricle  with  the 
bone,  and  an  offensive  discharge  of  pus,  but  no  serious  general 
symptoms  or  disease  of  other  parts  of  the  ear.  In  a  few  days 
loose  bone  was  detected  and  removed.  The  bone  does  not  heal. 
It  is  some  four  months  since  the  occurrence  of  the  original  in- 
flammation, but  the  surrounding  parts  are  now  free  from  ten- 
derness and  pain.  The  indications  of  treatment  are,  of  course, 
to  keep  the  opening  free  from  granulations  and  pus,  and  to  favor 
the  throwing  off  of  the  bone.  At  the  advanced  age  of  my  pa- 
tient, I  feel  obliged  to  content  myself  with  mild  measures.  I 
occasionally  scrape  the  granulations  and  also  the  surface  of  the 
bone  with  a  curette.  The  patient  lived  some  four  years  after  the 
above  was  written,  and  his  ear  gave  him  very  little  trouble,  al- 
though I  do  not  know  that  it  completely  healed. 

I  have  seen  one  case  of  nearly  complete  absence  of  the  audi- 
tory canal,  to  which  I  am  puzzled  to  assign  a  place,  or  rather 
I  am  uncertain  whether  it  belongs  among  the  cases  of  bony 
growth  from  inflammation  in  infancy,  or  in  intra-uterine  life,  or 
with  those  of  arrested  development.  It  may  perhaps  be  properly 
inserted  at  the  close  of  this  chapter. 

Dr.  W.  J.  Welch  sent  to  me,  for  advice,  a  very  interesting  case  of  closure  of 
the  auditory  canal.  The  patient  was  twenty  years  of  age,  said  to  be  "  deaf 
since  he  was  five  years  of  age."  His  ears  were  never  treated,  and  he  had  not 
grown  worse.  He  has  always  been  well  in  other  respects.  He  is  intelligent. 
His  ancestors  were  healthy  people.  He  never  had  a  discharge  from  his  ears,  and 
very  rarely  has  he  had  an  earache.  His  hearing  distance  is  :  right  ear,  -|^ ; 
left,  the  same.  The  voice  is  heard  behind  him  three  feet.  The  bone  conduc- 
tion seems  to  him  louder  than  aerial.  The  duration  is  about  the  same  as 
aerial.  The  auditory  canals  are  each  less  than  half  an  inch  deep,  and  funnel- 
shaped.  Air  enters  the  tympanic  cavity  by  Politzer's  method  of  inflation.  No 
change  in  the  hearing  distance  is  observed  after  inflation. 

I  considered  the  condition  as  congenital,  and  no  treatment 
was  urged  upon  the  patient,  although  an  explorative  opening  of 
the  canal  by  a  dentist's  drill  was  suggested.  Whether  this  bony 
closure  of  the  canal  was  the  result  of  intra-uterine  inflammation 
or  merely  of  arrested  development  of  the  canal,  remains  an  un- 
solved problem  to  me.  If  the  former  be  true,  then  the  case  is 
one  of  hyperostosis  of  the  canal.  It  is  possible  that  an  inflam- 
mation occurred  in  early  infancy,  which  led  to  closure  of  the 
canal.  In  the  chapter  upon  the  "  Consequences  of  Chronic 
Suppuration,"  this  subject  will  again  be  discussed. 


CHAPTER  VII. 

INSPISSATED  CERUMEN. 

Merely  a  Symptom  of  Aural  Inflammation. — Frequency  of  the  Affection. — Symp- 
toms.— Reported  Cases  of  Damage  to  the  Ear  from  the  Presence  of  Wax,  probably 
not  based  on  Correct  Observation. — Causes. — Treatment. — Cases. 

ALTHOUGH  I  am  convinced  that  the  hardening  of  cerumen  is 
merely  one  of  the  symptoms  of  aural  inflammation,  I  do  not 
feel  as  yet  justified  in  discussing  its  nature  and  treatment  in 
an  incidental  manner.  As  a  symptom,  inspissated  cerumen  is  so 
prominent  or  annoying,  that  it  has  been  classified  as  a  separate 
disease  for  a  long  time,  if  not  always,  although  it  is  merely,  in 
my  opinion,  a  consequence  of  an  inflammation. 

The  writers  on  otology  of  the  future,  will,  I  am  sure,  treat  of 
hardened  cerumen  in  connection  with  their  accounts  of  the  dis- 
eases of  the  external  and  middle  ear,  and  will  not  award  it  a 
place  by  itself,  although  the  writers  of  the  present  day  do  not  as 
yet  feel  justified  in  this  manner  of  discussing  it. 

Among  the  laity,  and  even  in  the  profession,  hardening  of 
the  ear-wax  is  generally  regarded  as  a  very  harmless  affection. 
It  is  also  considered  by  many  as  the  most  common  of  all  the 
diseases  of  the  ear.  The  first  treatment  that  many  aural  pa- 
tients receive  at  the  hands  of  their  medical  advisers,  is  a  vigor- 
ous syringing,  or  worse  still,  probing,  in  order  to  see  if  the  wax 
be  not  hardened. 

Now  the  facts  are,  that  inspissation  of  cerumen  is,  compara- 
tively, not  one  of  the  common  affections  of  the  ear,  and  that 
when  it  does  actually  occur,  it  is  by  no  means  the  simple  and 
harmless  disease  that  it  is  often  supposed  to  be.  Of  6,800  aural 
cases  observed  by  myself  in  private  practice,  only  497  were  what 
might  fairly  be  said  to  be  cases  of  inspissated  cerumen  ;  that  is 
to  say,  cases  in  which  the  impaction  of  ear-wax  was  the  chief 
of  the  aural  symptoms. 

In  the  Manhattan  Eye  and  Ear  Hospital,  of  the  20,103  aural 
cases  recorded  in  twenty-one  years,  2,228  are  classified  as  cases 
of  inspissated  cerumen.  Yet,  in  a  large  proportion  of  these,  it  is 


INSPISSATED   CEKUMEN.  159 

admitted  by  the  attending  surgeons,  that  the  hardened  wax  was 
but  a  symptom  of  what  may  have  been  more  serious  disease.  I 
have  found  that  it  is  the  habit  in  certain  circles,  to  speak  of 
the  hardening  of  cerumen,  as  if  it  were  a  trivial  affection  which 
almost  any  one  is  competent  to  manage,  and  one  that  needed  no 
considerable  attention. 

In  the  first  place,  no  one  is  competent  to  remove  hardened 
cerumen  without  careful  instruction,  and  in  the  second,  it  is  a 
significant  symptom,  the  careful  study  of  which  will  in  many 
cases  be  of  great  value  in  preserving  the  hearing  of  the  person 
affected  with  it.  Hardening  of  the  cerumen  often  occurs  in  the 
course  of  suppurative  processes  in  the  middle  ear,  as  well  as  in 
cases  of  chronic  non-suppurative  disease.  It  also  occurs  in  dis- 
ease of  the  internal  ear — the  nerve  or  labyrinth.  In  such  cases 
removal  of  the  wax  may  slightly  or  even  considerably  improve 
the  hearing.  If  it  be  improved,  a  superficial  examiner  may  be  led 
to  believe  that  impaction  of  the  wax  was  the  only  disease,  but  an 
exact  test  of  the  hearing  power  will  often  convince  him  that  the 
patient  still  has  defective  hearing,  even  though  it  be  greatly 
benefited  by  the  removal  of  a  large  plug  of  cerumen.  The  cases 
of  inspissated  cerumen,  in  which  the  hearing  becomes  perfect 
after  its  removal  were  in  the  beginning,  I  believe,  cases  of«in- 
flammation  of  the  canal  or  of  the  tympanic  cavity,  which  have 
run  their  course,  leaving  behind  them  the  wax  made  hard  by  the 
evaporation  produced  by  the  abnormal  heat,  when  the  canal  or 
tympanum  or  both  were  inflamed. 

Cases  are  sometimes  presented  to  me,  where  the  patient  can 
state  positively  that  there  was,  some  time  anterior  to  the  impair- 
ment of  hearing  from  the  blocking  up  of  the  ear,  a  period, 
although  a  brief  one,  of  decided  pain.  In  many  cases  also,  it  is 
easy  to  see  the  evidences  of  inflammation  in  the  epidermis  of  the 
canal,  after  the  wax  has  been  removed.  In  some,  I  grant  that 
it  is  not,  but  I  feel  confident  that  close  examination  will  show  in 
every  case,  a  probability  at  least,  that  an  inflammation  in  some 
part  of  the  ear,  a  morbid  condition,  preceded  the  period  when 
the  wax  was  not  removed  by  the  motions  of  the  jaw,  but  when 
it  remained  as  a  nucleus  about  which  the  whole  secretion  of 
the  canal  collected,  until  it  finally  became  an  obstruction  to 
hearing.  In  my  opinion,  the  proper  way  to  classify  inspissated 
cerumen  would  be  to  say,  for  example,  inflammation  of  the  canal 
with  inspissated  cerumen.  Suppurative  inflammation  of  the 
middle  ear  with  inspissated  cerumen,  and  so  forth.  I  speak  thus 
in  detail,  upon  this  point  that  inspissated  cerumen  is  but  a  symp- 
tom, because  I  believe  that  many  curable  cases  are  dismissed 
with  but  partial  relief,  because  it  is  thought  when  its  removal  is 


160  INSPISSATED    CERUMEN — SYMPTOMS. 

secured  and  the  hearing  is  much  improved,  that  impaction  of  the 
wax  is  the  only  disease.  In  many  of  these  cases,  unless  the  ear 
be  subjected  to  appropriate  treatment,  not  only  may  the  wax 
soon  become  again  inspissated,  but  the  fundamental  disease 
which  caused  the  impaction  of  the  wax  remains  uncured,  and  it 
may  become  permanent.  From  careful  observation,  I  believe  I 
may  state,  that  the  activity  of  the  ceruminous  glands  is  usually 
increased,  and  the  canal  becomes  exceedingly  hot  and  moist 
during  a  subacute  or  acute  catarrh  of  the  tympanic  cavity.  It 
is  in  this  increased  action  of  the  glands  that  the  beginning  of 
impacted  cerumen  is  to  be  sought. 

Symptoms. — The  prominent  symptoms  of  true  cases  of  inspis- 
sated cerumen  are:  1.  Sudden  impairment  of  hearing.  2.  Tin- 
nitus aurium.  3.  Vertigo.  4.  Pain  in  the  ear. 

The  practitioner  will  not  need  to  spend  much  time  in  deter- 
mining the  cause  of  such  symptoms.  If  they  be  produced  by 
impaction  of  the  cerumen,  a  glance  at  the  auditory  canal  by 
means  of  the  speculum  and  otoscope  will  determine  the  matter, 
or  at  least  it  will  give  us  positive  evidence  as  to  the  presence  of 
the  inspissated  substance.  It  need  hardly  be  said,  that  the  prac- 
tice of  probing  the  ear  to  determine  if  the  wax  be  hardened,  is 
an.extremely  unphilosophical  procedure,  while  it  is  not  without 
danger  to  the  membrana  tympani.  I  am  obliged  to  say,  how- 
ever, that  I  have  seen  several  cases  in  which  this  probing  has 
been  undertaken  without  ocular  examination ;  and  -where  in- 
flammation of  the  lining  of  the  canal,  of  the  drum-head,  and  in 
one  case  even  perforation  of  the  'membrane,  had  resulted  from 
the  manipulations  in  the  dark. 

The  appearance  of  inspissated  cerumen  is  very  character- 
istic. Wax  which  presses  upon  the  walls  of  the  canal  and  upon 
the  membrana  tympani,  in  adults,  is  of  a  dark  brown  or  black 
color,  and  usually  fills  the  canal.  In  children,  however,  in 
whom  the  disease  also  occurs,  the  wax  is  usually  of  a  yellow 
color,  and  is  more  apt  to  be  in  layers.  The  presence  of  even 
quite  an  amount  of  soft  yellow  cerumen,  which  still  leaves  an 
opening,  however  narrow,  down  to  the  drum-head,  can  hardly 
cause  any  unpleasant  symptoms. 

The  diagnosis  of  inspissated  cerumen  is  sometimes  obscured, 
by  the  useless  habit  indulged  in  by  so  many  of  the  laity  and  of 
the  profession  also,  of  pouring  olive  or  other  oils  into  the  audi- 
tory canal  on  the  appearance  of  any  aural  symptoms.  A  lady 
once  came  from  St.  Louis  to  consult  a  New  York  physician  in 
regard  to  a  loss  of  hearing.  She  had  been  seen  by  no  less  than 
six  medical  men,  all  of  whom  had  prescribed  applications  to  be 
dropped  into  the  ear,  and  none  of  whom  had  made  an  examina- 


INSPISSATED    CERUMEN— SYMPTOMS.  161 

tion.  She  had  suffered  for  six  years  from  the  great  impairment 
of  hearing,  and  came  to  New  York  as  a  last  resort.  Having 
arrived  here,  she  was  sent  to  me.  I  found  the  ears  filled  with 
oils,  but  beneath  all  this,  hardened  cerumen,  which  was  easily 
removed ;  and,  although  her  hearing  had  been  impaired  for  so 
long  a  time,  the  removal  of  the  wax  restored  it  to  the  normal 
power,  so  that  she  heard  ordinary  conversation  with  ease,  and  a 
watch  several  feet.  In  this  case,  I  did  not  imagine,  until  the 
ears  were  cleansed  by  the  syringe,  that  impacted  cerumen  was 
the  cause  of  the  loss  of  hearing.  I  could  scarcely  believe,  that 
oils  would  be  persistently  dropped  in  an  ear  by  so  many  different 
advisers,  before  the  membrana  tympani  had  been  examined. 

The  tuning-fork  will  be  of  use,  if  the  inspissated  cerumen  be 
confined  to  one  side  in  determining  the  prognosis  ;  but  practi- 
cally the  better  plan  is  to  defer  any  statement  as  to  the  prog- 
nosis until  the  cerumen  is  removed. 

In  cases  of  disease  of  the  acoustic  nerve  with  impacted  wax, 
the  tuning-fork  will  sometimes  be  heard  better  by  bone  than  by 
aerial  conduction,  but  when  the  wax  is  removed,  the  hearing  re- 
mains impaired,  but  the  tuning-fork  is  heard  better  through  the 
air  than  through  the  bones.  Of  course,  if  the  hearing  be  nearly 
or  absolutely  gone  from  disease  of  the  nerve,  the  presence  of 
wax  will  make  no  difference  in  the  ability  to  hear  the  tuning- 
fork,  so  that,  if  the  tuning-fork  be  not  heard  better  through  the 
bones  with  impacted  wax,  the  prognosis  as  to  improvement  of 
the  hearing  is  very  poor. 

The  loss  of  hearing  from  hardening  of  the  cerumen,  as  has 
been  intimated,  is  apt  to  occur  very  suddenly.  I  have  seen  sev- 
eral cases  where  patients  could  tell  the  very  instant  when  the 
ear  "closed  up,"  as  they  often  say.  The  jolting  of  a  ride  in  a 
rumbling  vehicle  often  displaces  the  hardened  material,  and 
presses  it  into  the  canal,  causing  troublesome  symptoms  in  an 
instant ;  and,  as  I  have  said,  these  symptoms  do  not  occur,  no 
matter  how  much  cerumen  may  be  in  the  ear,  until  the  impac- 
tion  takes  place,  when  the  loss  of  hearing,  the  tinnitus  aurium, 
and  the  increased  resonance  of  the  patient's  own  voice,  calls  his 
attention  to  the  ear. 

Pain  of  the  most  distressing  nature  sometimes  occurs  from 
the  impaction  of  cerumen.  I  remember  one  case  where  ano- 
dynes had  been  used  for  ten  days  to  relieve  a  pain  in  the  ear, 
which  an  examination  showed  was  the  result  of  the  affection 
now  under  consideration.  In  another  case,  that  of  a  young 
lady,  suppuration  of  the  drum-head  resulted  from  the  long-con- 
tinued impaction  of  cerumen.  This  suppuration  was  preceded 
by  very  severe  pain,  from  which  no  relief  was  experienced  until 
11 


162  MENTAL   DEPRESSION   FROM   HARDENED   WAX. 

the  mass  of  cerumen  was  evacuated  spontaneously,  like  a  cork 
from  a  bottle  of  champagne,  and,  as  the  patient  stated,  with  a 
report  like  that  of  a  pistol.  The  removal  of  a  plug  of  cerumen 
from  the  auditory  canal  of  the  other  side,  a  plug  that  was  very 
tightly  wedged  in,  saved  the  patient  from  a  similar  experience 
on  that  side. 

These  rare  cases  of  suppuration  caused  by  wax,  should  not 
be  confounded  with  those  frequent  ones  of  chronic  suppuration 
where  the  wax  hardens  over  the  opening  of  the  membrana 
tympani. 

It  is  probable  that  some  of  the  cases  reported  by  the  earlier 
authors  as  instances  of  great  damage  to  the  ear  from  inspis- 
sated cerumen,  were  cases  of  this  kind.  Toynbee's '  cases  of 
absorption  of  the  bone,  imbedding  of  wax  in  the  mastoid  cells, 
are  possibly  only  cases  where  hardened  wax  supervened  upon 
chronic  suppuration  of  the  middle  ear. 

Among  the  cases  that  are  appended  to  this  chapter,  will  be 
found  another  where  excruciating  pain  was  one  of  the  promi- 
nent symptoms  of  a  case  of  inspissated  cerumen.  Yet  neither 
pain  nor  vertigo  are  the  ordinary  symptoms  of  this  disease ;  im- 
pairment of  hearing  and  tinnitus  are  the  usual  ones. 

Great  depression  of  spirits,  almost  becoming  melancholia, 
was  observed  in  a  case  reported  by  Dr.  Edward  T.  Ely  and 
myself.2 

MENTAL  DEPRESSION  FROM  IMPACTED  WAX. 

Mr.  T ,  set.  18,  has  been  seen  at  intervals  for  several  years  on  account  of 

a  chronic  suppuration  in  the  right  middle  ear.  The  left  ear  was  normal.  On 
May  15,  1879,  the  right  ear  was  in  very  good  condition ;  the  hearing  was  £$,  and 
there  was  no  discharge.  Patient  came  again  on  September  24th,  complaining 
that  since  June  he  had  suffered  from  "a  feeling  of  heaviness  in  his  head." 
Was  "  unable  to  concentrate  his  mind  on  anything  for  more  than  a  few  min- 
utes." Felt  as  if  he  must  give  up  his  studies  (in  which  he  was  very  much  inter- 
ested), and  wished  to  know  whether  he  must  leave  college.  Thought  his  deaf- 
ness had  increased,  but  had  no  pain,  tinnitus  or  discharge.  The  patient  was 
sullen  and  very  despondent.  Otherwise  his  health  seemed  to  be  excellent.  He 
was  very  reticent  by  nature. 

H.  D.,  E.  -f^.  External  auditory  canal  filled  with  hard  wax.  After  remov- 
ing the  wax,  the  hearing  became  \%,  and  the  tympanic  cavity  looked  as  it  had  at 
former  visits ;  there  was  no  discharge. 

The  patient  obtained  speedy  relief,  and  in  a  few  days  reported  the  discom- 
fort about  his  head  gone.  He  was  then  as  cheerful  as  usual. 

This  case  was  interesting,  as  illustrating  the  disturbing  influence  of  impacted 
wax,  even  with  an  entire  absence  of  tinnitus. 

1  Text-book,  English  edition,  p.  51. 
*  Archives  of  Otology,  Vol.  IX. ,  p.  16, 


INSPISSATED   CERUMEN — CAUSES.  163 


CAUSES. 

The  causes  of  hardening  of  the  wax  in  the  auditory  canal  are 
not  as  well  settled  as  we  could  wish.  As  I  have  already  observed, 
I  no  longer  believe  that  it  is  an  independent  affection,  or  a  dis- 
ease only  of  the  ceruminous  glands.  There  are  cases,  however, 
in  which  at  the  time  of  the  removal  of  the  inspissated  cerumen, 
its  presence  is  the  only  bar  to  a  perfect  recovery  of  the  hearing 
power.  In  such  cases  the  disease  which  caused  the  wax  to 
harden  has  passed  away,  and  it  only  remains  as  a  foreign  body. 
Yet  in  by  far  the  majority  of  cases  the  hearing  is  not  fully  re- 
stored by  the  removal  of  the  wax.  I  will  tabulate  the  diseases 
in  which  hardening  of  the  wax  may  occur. 

I. — Chronic  Suppuration  of  the  Middle  Ear. 

Hardening  of  cerumen  in  such  cases  is  not  always  injurious. 
A  layer  of  hard  wax  sometimes  serves  as  a  good  artificial  drum- 
head, and  improves  the  hearing.  When  the  mass  has  become 
thick  enough  to  cause  pressure,  pain,  tinnitus  and  vertigo  may 
result,  and  it  should  be  removed.  It  is  important,  therefore,  in 
extremely  chronic  cases  of  suppuration  of  the  middle  ear,  to 
remember  that  a  layer  of  black  wax  may  be  sometimes  more 
profitably  left  than  removed,  since  it  sometimes  acts  as  an  arti- 
ficial membrana  tympani.  It  is  to  be  understood,  however,  that 
this  is  not  the  rule  when  there  is  a  hope  of  healing  the  mem- 
brana tympani  by  local  treatment. 

II. — Chronic  Non-Suppurative  Inflammation  of  the  Middle  Ear. 

The  symptoms  of  patients  suffering  from  this  form  of  disease 
are  often  aggravated  by  impaction  of  the  cerumen.  So  unob- 
servant are  many  as  to  a  loss  of  hearing,  that  until  a  plug  of 
wax  has  closed  the  canal  and  rendered  hearing  of  ordinary 
conversation  carried  on  near  them,  very  difficult,  do  they  admit 
that  their  hearing  is  at  all  defective.  In  such  cases  the  rule  is 
without  exception  to  remove  all  the  hardened  material. 

III. — Diffuse  Inflammation  of  the  Auditory  Canal. 

I  have  seen  hardening  of  the  wax,  especially  in  children,  in 
the  course  of  this  disease.  As  has  been  before  intimated,  the 
black  color  that  usually  indicates  hard  wax  in  adults  is  not 
found,  when  it  is  impacted  in  the  ears  of  children.  The  mixture 
of  layers  of  epidermis  with  the  wax  is  more  marked  in  these  cases 
than  in  others. 


164  INSPISSATED   CERUMEN — CAUSES. 

IV. — Foreign  Bodies. 

The  cerumen  may  become  impacted  in  the  ear  in  cases  where 
foreign  bodies  have  been  placed  in,  or  have  entered  the  auditory 
canal,  and  have  not  been  removed.  I  have  on  several  occasions 
removed  hardened  wax  that  contained  insects  that  had  entered 
the  ear.  In  one  case,  that  of  a  little  boy,  the  parents  remembered, 
on  questioning,  that  he  had  once,  about  a  year  before,  complained 
of  pain  in  his  ear  for  a  few  hours,  and  that  he  had  said  some- 
thing was  in  his  ear.  The  pain  was  stilled  and  the  occurrence 
was  forgotten  until  new  symptoms  appeared,  such  as  impairment 
of  hearing  and  tinnitus.  An  examination  revealed  impacted 
cerumen,  in  the  centre  of  which  was  found  an  insect. 

V. — Exostosis  and  Hyperostosis  of  the  Canal. 

Impacted  cerumen  occurring  in  a  case  where  the  canal  is 
narrowed  by  a  bony  growth,  is  difficult  to  manage,  for  it  is 
particularly  difficult  to  remove  the  wax  when  it  lies  behind  the 
contraction  of  the  osseous  canal.  I  have  one  such  case  in  my 
mind  as  I  write,  that  of  a  physician  from  the  South,  who  in  his 
annual  visits  to  the  North,  is  obliged  to  devote  as  much  time  to 
getting  the  hardened  wax  from  his  auditory  canal,  as  is  usually 
devoted  to  the  care  of  the  teeth.  The  presence  of  the  wax  great- 
ly diminishes  his  already  impaired  hearing.  Even  a  thin  layer 
lying  on  a  part  of  the  drum-head  is  sufficient  for  this.  In  his 
case,  the  connection  of  the  hardening  and  massing  of  the  ceru- 
men, with  an  inflammatory  condition  of  the  canal  is  very  plain. 

VI. — Parasitic  Inflammation. 

Impaction  of  cerumen  is  not  at  all  unlikely  to  occur  in  con- 
junction with  parasitic  inflammation  of  the  canal.  As  was  inci- 
dentally mentioned  in  the  preceding  chapter,  wax  may  harden 
upon  a  growth  of  aspergillus  in  the  canal  and  upon  the  drum- 
head. 

While  these  pages  are  passing  through  the  press  I  have  un- 
der my  care  a  boy  of  eight  years  of  age,  who  came  to  me  some 
four  weeks  ago  on  account  of  defective  hearing.  Both  his  audi- 
tory canals  were  found  to  be  filled  with  impacted  cerumen,  which, 
as  is  apt  to  be  the  case  in  children,  was  removed  slowly  and 
with  difficulty.  Dr.  Emerson,  my  associate,  has  spent  many 
hours  upon  the  case,  using  the  syringe,  curette,  probe,  and  for- 
ceps at  each  sitting.  Wlnen  several  layers  of  wax  had  been  re- 
moved, we  found  aspergillus  of  luxuriant  growth  underneath, 
clinging  closely  to  the  canal  and  membrana  tympani. 


INSPISSATED   CERUMEN — CAUSES.  165 

Sometimes  the  patients  with  inspissated  cerumen  say  that 
they  perspire  excessively ;  and  again,  they  are  not  at  all  aware 
of  any  such  peculiarity.  Often,  indeed,  they  state  positively  that 
they  do  not  perspire  any  more  than  is  natural.  I  think,  there- 
fore, we  must  reject  this  from  among  the  causes  of  this  disease, 
although  it  is  given  by  some  authors. 

I  have  no  doubt  that  the  bad  habit  of  cleansing  the  audi- 
tory canal  with  the  end  of  a  towel,  or  with  an  aurilave — a  bit  of 
sponge  fastened  on  a  handle — or  the  like,  has  a  tendency  to  pack 
the  cerumen  in  the  canal ;  but  after  all,  a  cause  must,  I  think, 
be  sought  for  behind  this,  and  this  is  to  be  found  in  an  inflam- 
mation of  the  middle  ear,  which  has  extended  to  the  auditory 
canal,  or  in  an  inflammation  of  the  canal  itself. 

I  have  observed  that  almost  all  patients  suffering  from  inspis- 
sated cerumen  ascribe  the  attack  to  "cold"  which  they  have 
taken.  In  many  of  these  cases  no  evidence  is  found  to  sub- 
stantiate the  theory,  for,  as  all  my  readers  know,  patients  are 
very  apt  to  ascribe  all  kinds  of  diseases  to  cold,  even  when  they 
cannot  positively  remember  that  they  have  suffered  from  a  cold 
in  the  head,  throat,  or  chest.  Yet  many  cases  have  come  to  me, 
in  which  there  was  a  naso-pharyngeal  catarrh  coincident  with 
the  impaction  of  cerumen,  or  with  the  aural  symptoms. 

I  suppose  a  very  slight  swelling  of  the  auditory  canal  would 
prevent  the  free  removal  of  the  cerumen,  which  naturally  takes 
place  from  the  motion  of  the  lower  jaw,  as  it  presses  upon  the 
lower  part  of  the  wall  of  the  meatus.  When  the  wax  has  once 
collected,  partial  evaporation  of  its  watery  contents  occurs,  and 
we  get  the  characteristic  black  color,  and  the  mass  becomes,  on 
its  surface  at  least,  as  hard  as  soft  wood,  and  in  rare  cases  as 
hard  as  some  kinds  of  stone. 

Cases  enough  have  been  seen  to  show,  that  inflammation  of 
the  canal  does  favor  inspissation  of  the  cerumen  ;  the  only  ques- 
tion upon  which  any  doubt  may  be  thrown  is,  whether  impaction 
of  cerumen  does  ever  occur  without  an  antecedent  inflammation, 
and  from  purely  mechanical  causes,  such  as  packing  of  the  secre- 
tion by  improper  attempts  to  cleanse  the  canal,  or  from  a  peculiar 
tendency  to  excessive  action  of  these  numerous  glands.  Certain 
it  is,  that  some  cases  require  only  local  treatment,  and  that  what- 
ever inflammation  preceded  the  evaporation  of  the  fluid  of  the 
cerumen,  was  fully  removed  when  the  patients  came  under  treat- 
ment. 

Many  patients  suffering  from  chronic  non-suppurative  inflam- 
mation, complain  that  their  ears  secrete  no  wax.  This  state  of 
things  is  due  to  two  facts  :  One  is,  that  such  patients  are  very 
apt  to  syringe  their  ears  very  frequently,  and  thus  remove  all 


166  GLYCERINE   AS  A   REMEDY   FOR   DEAFNESS. 

the  cerumen  as  fast  as  it  forms.  The  other  is,  that  the  chronic 
catarrhal,  or  proliferating  process,  probably  extends  to  the  audi- 
tory canal,  and  interferes  with  the  functions  of  the  ceruminous 
glands. 

Under  the  guidance  of  Mr.  T.  Wakely,  who  published  an 
account  of  the  wonderful  virtues  of  glycerine  in  the  London 
Lancet,1  the  profession  were  at  one  time  very  much  in  the  habit 
of  recommending  the  use  of  this  agent  to  re-establish  the  secre- 
tion of  cerumen.  Mr.  Wakely  even  published  a  work  entitled 
"Clinical  Reports  on  the  Use  of  Glycerine  in  the  Treatment  of 
Certain  Forms  of  Deafness."  Mr.  Wilde  showed  that  the  reporter 
of  these  cases  was  not  "conversant  with  either  the  normal  or 
pathological  appearances  of  the  ear,"  and  glycerine,  after  a  fair 
trial,  which  is  still  kept  up  by  some  physicians,  proved  to  be  of 
no  avail  in  relieving  impairment  of  hearing.  Its  only  value  is 
as  an  emollient  to  soothe  an  irritated  or  dry  canal.  It  should  be 
diluted  with  water  when  used  in  this  way. 

Its  use  for  the  restoration  of  the  secretion  of  cerumen  was 
about  as  rational  as  the  other  instillations,  of  which  an  account 
has  been  given  in  the  introductory  chapter.  Yet  in  our  own 
century,  a  surgeon  to  a  London  hospital  gravely  recommended, 
as  a  portion  of  a  new  cure  for  deafness,  "the  finest  curled  wool 
on  the  sheep's  head,  carefully  cut  with  scissors,  and  washed  in 
hot  water,"  and  added  "that  the  best  wool  is  that  procured  from 
a  small  German  sheep ;" z  while  in  the  same  city,  Wakely's  book 
was  gravely  noticed  as  a  contribution  to  clinical  medicine. 

From  present  appearances  another  quarter  of  a  century  will 
pass  away,  before  many  physicians  will  cease  to  advise  the  use 
of  glycerine  and  sweet  oil,  for  a  disease  of  the  ear,  of  the  exact 
nature  of  which  they  know  nothing.  Were  it.  not  that  valuable 
time  is  often  lost  in  the  treatment  of  inflammation  of  the  ear, 
in  many  cases  where  this  advice  is  given,  there  would  not  be 
much  to  regret,  since  in  many  instances  the  glycerine  or  oil 
softens  the  hardened  wax,  so  that  its  position  is  changed  at 
least.  Sometimes  it  even  effects  a  removal  of  it  without  the 
use  of  a  syringe,  but  for  one  case  where  inspissated  cerumen 
actually  exists,  when  this  advice  is  given  without  an  examina- 
tion, there  are  a  score  where  there  is  no  hard  wax  to  soften, 
and  where  the  advice  is  positively  harmful.  Glycerine,  as  usu- 
ally prescribed  for  the  ear,  has  very  few  antiphlogistic  virtues. 
It  usually  perpetuates  rather  than  cures  an  inflammatory  process. 

Treatment. — The  treatment  of  inspissated  cerumen  is  exceed- 
ingly simple.  The  hardened  material  should  be  removed  by  the 

1  Wilde's  Aural  Surgery,  p.  38.  *  Wilde,  loc.  cit.,  p.  4& 


INSPISSATED   CERUMEN — TREATMENT.  167 

use  of  the  syringe  and  warm  water.  The  syringing  should  be 
performed  in  the  manner  that  has  been  depicted  on  page  133. 
In  the  majority  of  cases  but  a  few  minutes  are  necessary  to  re- 
move the  mass.  In  some  cases,  however,  we  are  compelled  to 
use  a  solvent  for  a  few  hours  prior  to  the  syringing  process.  I 
usually  use  a  saturated  solution  of  the  bicarbonate  of  soda  for 
this  purpose.  The  cerumen  is  sometimes  so  hard,  and  so  tightly 
wedged  into  the  auditory  canal,  that  a  daily  sitting  for  a  week 
or  more  is  necessary  to  its  removal.  I  have  notes  of  several 
such  cases.  In  one  of  them,  I  finally  softened  the  mass  by  the 
use  of  fuming  nitric  acid,  after  having  completely  failed  to 
make  any  impression  upon  it  by  alkaline  solutions  or  oils. 

Professor  S.  D.  Gross  recommended  a  pick  and  curette  for 
the  removal  of  inspissated  cerumen.  He  says  :  "Ear-wax,  how- 
ever hard,  or  however  firmly  impacted,  is  more  readily  removed 
with  such  an  instrument  than  with  any  other  contrivance  of 
which  I  have  any  knowledge."  '  I  am  constrained  to  say,  that 
I  consider  such  advice  from  so  eminent  a  source  as  the  late  Pro- 
fessor in  the  Jefferson  Medical  College,  calculated  to  give  a 
dangerous  and  false  impression  as  to  the  proper  method  of  re- 
moving ear-wax.  The  syringe  and  warm  water  will  be  found 
to  be  the  only  means  that  are  necessary  in  ninety  cases  out  of  a 
hundred.  The  use  of  the  "pick  and  curette,"  or  of  any  pointed 
instrument,  is  a  dangerous  means  of  removing  inspissated  ceru- 
men, except  in  the  hands  of  men  of  very  large  surgical  experi- 
ence, who  have  learned  to  treat  ears  as  if  they  were  soap-bubbles. 
It  is  only  in  the  rare  cases  in  which  the  syringe  fails  that  the 
•use  of  an  instrument,  employed  under  a  good  illumination  by 
means  of  the  mirror  and  forehead  band,  should  be  resorted  to. 

In  some  cases  it  will  be  necessary  to  lift  the  first  layer  of 
hard  wax  with  a  delicate  probe  before  the  syringe  will  make  any 
impression  upon  it.  In  others,  this  will  be  necessary  even  down 
to  the  last  layer.  In  such  cases  the  curettes  of  Buck  and  Politzer, 
used  under  good  illumination  are  of  great  assistance.  Too  great 
stress,  however,  cannot  be  laid  upon  the  necessity  for  care  in  the 
use  of  instruments  upon  the  auditory  canal,  especially  near  the 
drum-head.  In  the  hands  of  the  average  practitioner,  the  syringe 
is  the  best  instrument  for  the  removal  of  impacted  cerumen, 
because  it  is  usually  efficient  and  always  safe.  Dr.  Pomeroy* 
recommends  a  syringe  "with  a  flange  and  a  long  narrow  tip"  for 
the  removal  of  hardened  wax.  The  stream  of  water  from  the  in- 
strument is  no  doubt  efficient,  but  I  think  this  syringe  in  unprac- 

1  American  Journal  of  the  Medical  Sciences,  October,  1864 
9  Text-book,  p.  85. 


168  INSPISSATED   CERUMEN — TREATMENT. 

tised  hands  is  more  dangerous  than  a  probe,  and  I  still  use  a 
short  nozzle  as  seen  on  page  132.  When  it  becomes  necessary  to 
make  an  opening  in  wax  upon  which  the  stream  of  water  may 
act,  nitric  acid  may  be  used,  or  a  saturated  solution  of  caustic  pot- 
ash (Blake),  a  small  hole  being  burned  in  the  centre  of  the  mass. 

The  auditory  canal  may  contain  a  surprisingly  large  quantity 
of  hardened  cerumen,  and  it  is  necessary  to  examine  the  ear 
quite  often  during  the  syringing  process,  in  order  to  see  how 
much  remains,  lest  we  continue  the  injections  after  the  wax  is 
removed,  and  thus  injure  the  drum-head.  All  the  wax  should 
be  removed.  The  thinnest  scale  or  flake  left  upon  the  drum- 
head, is  sometimes  sufficient  to  keep  up  the  disturbing  symptoms. 
I  have  seen  several  cases  where  the  diagnosis  was  correctly 
made,  and  the  syringing  undertaken,  and  yet  the  symptoms 
were  not  relieved,  because  a  small  flake  of  wax  was  left  upon 
the  drum-head. 

The  membrana  tympani  is  usually  found  very  much  reddened 
after  the  removal  of  the  wax  ;  but  this  is  probably  due  to  the  in- 
jections of  warm  water.  It  is  also  sometimes  pressed  inward. 
This  may  be  due  to  the  mechanical  pressure  which  has  been  ex- 
erted upon  it  by  the  cerumen,  or  to  the  catarrh  of  the  tympanic 
cavity  which  so  often  accompanies  or  causes  this  disease. 

If  the  hearing  is  very  much  improved  after  the  removal  of 
the  wax,  the  ear  should  be  protected  from  the  shock  of  sounds 
by  a  little  pledget  of  cotton  placed  lightly  in  the  meatus.  If  the 
drum-head  be  sunken  inward,  Politzer's  method  of  inflating  the 
middle  ear,  or  the  Eustachian  catheter,  should  be  employed  to 
restore  it  to  a  normal  position.  Since  some  persons  are  disposed' 
to  frequent  attacks  of  inspissated  cerumen,  it  is  well  to  advise 
them  to  have  the  ear  syringed  with  warm  water  once  in  two  or 
three  months.  It  is  probable  that  it  requires  a  longer  time  than 
this,  for  cerumen  to  become  so  hard  or  so  tightly  packed  in  the 
canal,  that  it  cannot  be  readily  removed  by  the  patient  or  a  non- 
medical  friend. 

It  is  always  well  to  examine  both  ears,  even  when  only  one  is 
complained  of.  I  have  often  found  the  ear  in  which  the  hearing 
was  still  unimpaired,  quite  as  full  of  wax  as  the  other,  although 
it  iiad  not  yet  become  pressed  upon  the  drum-head,  and  thus  had 
given  no  trouble. 

I  append  a  few  cases,  which  illustrate  what  has  been  said, 
and  which  will,  perhaps,  contribute  to  a  knowledge  of  the  eti- 
ology of  the  disease. 

CASE  I. — Buzzing  Noise  for   Two  Days,   then  Pain — Inspissated  Cerumen. — 

March  5,  1873,  Mr.  De  S ,  set.  28,  consulted  me  about  a  pain  in  his  ear. 

Two  days  since  he  experienced  a  "buzzing  noise"  in  the  ear,  and  last  night  he 


INSPISSATED    CERUMEN — CASES.  169 

had  severe  pain  in  it,  which  was  relieved  by  some  liquid  application.  The  buzz- 
ing noise  still  continues,  and  he  cannot  hear  well  from  the  left  side. 

The  hearing  distance  is :  Eight  ear,  normal ;  Left  ear,  ^gj  or  the  watch  is 
heard  when  pressed  upon  the  auricle. 

Tuning-fork  is  heard  much  better  on  the  left  side. 

Diagnosis  :  Inspissated  cerumen  in  left  ear. 

The  mass  was  removed  by  syringing,  and  the  hearing  distance  became  51  in 
a  few  moments. 

CASE  II. — Head  Symptoms  for  some  Months,  ascribed  to  Sunstroke — Treated 
for  Cerebral  Disease,  without  Examination  of  the  Ears — Inspissated  Cerumen — Re- 
moval—Cure.— A.  B ,  coachman,  at  New  York  Eye  and  Ear  Infirmary,  in 

1864.  The  patient  complained  of  head  symptoms  for  some  months.  He  ascribes 
them  to  a  sunstroke.  On  cross-examination  it  was  found  that  he  had  never  act- 
ually suffered  from  sunstroke ;  but  that  since  his  head  symptoms — chiefly 
buzzing  in  the  ear  and  deafness — had  begun,  he  imagined  that  they  were  caused 
by  a  fancied  sunstroke. 

He  stated  that  he  had  been  treated  in  a  New  York  hospital  for  some  weeks, 
but  without  benefit.  His  ears  had  never  been  examined,  and  he  had  concluded 
to  have  their  condition  investigated,  as  many  of  the  symptoms  which  made  him 
' '  bad  in  the  head  "  were  referred  to  his  ears. 

An  examination  showed  inspissated  cerumen  in  both  ears.  I  have  mislaid 
the  record  which  gave  an  account  of  his  hearing  power ;  but  all  the  trouble- 
some symptoms  were  at  once  relieved  by  the  removal  of  the  mass,  which  was 
done  by  the  use  of  the  syringe. 

This  case  is  almost  as  striking  as  that  related  by  Troltsch. 
in  which  a  poor  fellow  was  blistered  and  cupped  to  the  verge  of 
severe  depression  for  a  supposed  concussion  of  the  brain,  which 
proved  to  be  caused  by  inspissated  cerumen. 

CASE  III. — Abscesses  near  the  External  Meatus — Impaction  of  Cerumen — Res- 
toration of  Hearing  after  Removal  of  the  Cerumen. — The  following  case  shows,  I 
think,  that  a  swelling  of  the  canal  may  prevent  the  normal  exit  of  the  cerumen, 
and  thus  favor  its  impaction  : 

Miss  J ,  set.  29,  consulted  me  March  23,  1873,  on  account  of  her  ears, 

and  gave  the  following  history  :  For  fourteen  or  fifteen  years  she  had  suffered 
at  intervals  from  abscesses  in  both  ears.  The  hearing  has  been  seriously  im- 
paired on  the  right  side  from  an  ulcer  resulting  from  scarlet  fever,  since  she 
was  five  years  old.  For  the  past  two  or  three  mouths  the  hearing  has  been 
impaired  in  the  left  ear,  and  she  has  siiffered  from  abscesses  near  the  external 
meatus,  which  have  caused  great  swelling  and  tenderness  of  the  parts.  The 
impairment  of  hearing  was  most  marked  in  the  morning.  For  the  last  four 
weeks  she  has  been  constantly  deaf,  although  for  a  few  moments  a  few  days  ago . 
she  heard  very  well ;  she  then  felt  as  if  something  had  broken  in  the  ear. 

Hearing  distance,  tested  by  the  watch  :  Eight  ear,  -.,>;  ;  Left  ear,  -4Q8-. 

Diagnosis. — Eight  ear,  chronic  suppuration  in  tympanic  cavity.  Left  ear, 
inspissated  cerumen.  A  small  furuncle  was  found  in  the  outer  part  of  the 
canal,  which  was  a  very  narrow  one. 


170  CASE   OF   RECURRENT   LN'SPISSATION   OF   CERUMEN. 

The  mass  of  cerumen  was  removed  in  about  twenty  minutes  by  syringing, 
when  the  hearing  distance  became  -/«. 

Politzer's  method  of  inflating  the  ear  was  then  employed. 

March  6th  :  H.  D.,  if. 

After  the  use  of  Politzer's  method,  the  hearing  distance  became  f f. 

The  above  case  illustrates  the  theory  of  the  preceding  chap- 
ter, that  inspissated  cerumen  is  in  reality  but  one  of  the  symp- 
toms of  certain  forms  of  inflammatory  affection.  In  this  case 
the  inflammation  had  not  fully  run  its  course,  for  the  canal  was 
red  and  swelled.  Perhaps,  indeed,  this  was  an  habitual  condi- 
tion of  the  part. 

CASE  IV. — Recurrent  Attacks  of  Inspissated  Cerumen  for  Twenty  Years — Ul- 
ceration  of  Membrana  Tympani  during  Two  Attacks — Recovery,  but  Inspissation 
of  Cerumen  continues  to  recur. — I  have  under  observation  and  care  a  gentleman 
of  about  thirty-eight  years  of  age,  who  has  suffered  from  attacks  of  inspissation 
of  cerumen  for  more  than  twenty  years.  He  has  been  under  my  care  for  four- 
teen years.  At  first  the  wax  hardened  at  intervals  of  months,  but  now,  espe- 
cially in  the  summer,  the  intervals  are  so  short,  that  the  patient  is  obliged  to 
present  himself  once  a  month  for  examination,  and  generally  for  the  removal  of 
the  plug  that  has  formed  in  one  or  both  ears. 

Five  years  ago,  the  hardening  of  the  wax  was  followed  by  ulceration  of  the 
outer  layer  of  the  membrana  tympani.  This  healed  under  the  use  of  nitrate  of 
silver.  A  few  months  after,  a  granulation  was  found  at  the  bottom  of  the  canal, 
and  an  attack  of  pain  occurred.  The  canal  became  red  and  swollen  at  the  junc- 
tion of  the  auricle  and  the  mastoid.  The  canal  and  drum-head  were  again 
treated  by  the  warm  douche,  and  in  a  few  months  the  wax  again  accumulated 
and  hardened.  A  year  after  the  patient  again  had  an  abscess  in  the  right  ear. 
Although  the  wax  hardens  in  each  ear,  inflammation  has  as  yet  only  occurred 
in  the  right  one.  This  probably  perforated  the  drum-head,  but  it  healed 
again. 

The  inflammation  extended  from  the  canal  inward,  and  hence  it  was  not  so 
easy  to  decide  as  to  whether  it  had  passed  through  the  layers  of  the  drum-head 
or  not.  The  last  inflammation  that  as  yet  affected  the  ear,  in  conjunction  with 
the  impaction  of  the  cerumen,  occurred  a  year  and  a  half  ago.  This  did  not 
perforate  the  drum-head,  and  healed  under  the  use  of  iodoform.  The  patient 
now  comes  for  examination  every  few  weeks,  in  summer  especially,  and  by  re- 
moving the  wax  before  the  plug  has  formed,  we  hope  to  prevent  the  recurrence 
of  inflammation.  After  a  careful  study  of  this  case,  I  have  not  been  able  to 
satisfy  myself  as  to  what  causes  the  wax  to  harden. 

That  the  inflammation  follows,  rather  than  causes  the  inspissation,  seems  to 
be  true  here.  The  patient  is  a  gentleman  of  excellent,  even  vigorous  general 
health,  whose  habits  are  correct,  and  whose  position  in  life  enables  him  to  take 
the  best  of  care  of  himself  in  every  respect.  I  have  tried  in  vain,  to  prevent  the 
accumulation  of  the  wax  by  pencilling  the  canal  with  nitrate  of  silver. 

It  ought  finally  to  be  stated,  that  although  the  hearing  has  often  been  much 
impaired  for  some  time,  it  as  yet  remains  practically  normal,  except  when  the 
patient  is  suffering  from  a  recurrence  of  impaction  of  cerumen. 


EFFECTS   OF   QUININE   UPON   THE  EAR.  171 

The  following  case,  which  may  be  considered  a  remarkable 
one,  illustrates  not  only  the  etiology  of  inspissated  cerumen,  but 
also  the  effect  of  quinine  upon  the  ear ;  and  I  insert  it  as  much 
to  show  the  influence  of  this  agent  upon  the  auditory  apparatus, 
as  for  its  bearing  upon  the  subject  now  under  discussion. 

It  has  already  been  published,1  but  I  think  it  worthy  a  wider 
circulation  than  it  has  hitherto  obtained. 

CASE  V. — Inflammation  of  the  Auditory  Canal,  caused  by  Quinine — Impaction  of 
Cei'umen — Use  of  Nitric  Acid  to  effect  Removal. — On  the  3d  of  May,  1870,  I  was 

consulted  by  Dr.  N ,  set.  34,  on  account  of  his  throat  and  ears.  He  stated 

that  he  had  had  acute  pharyngeal  and  laryngeal  disease  some  ten  years  before. 
He  also  informed  me  that  neither  he  nor  his  parents  have  any  recollection  of  any 
serious  difficulty  with  his  ears  prior  to  the  date  of  the  attack,  from  whose  con- 
sequences he  is  now  suffering.  The  laryngeal  inflammation  was  followed  by 
chronic  naso-pharyngeal  catarrh,  and  in  1863  he  was  obliged  to  take  five-grain 
doses  of  quinine  for  some  weeks  on  account  of  nervous  prostration  from  malarial 
fever  contracted  in  the  Southern  States.  These  doses  were  increased  to  ten 
grains,  and  cinchonism  was  produced.  The  symptoms  of  cinchonism  were,  ring- 
ing in  the  ears  and  dizziness.  In  1864,  the  doctor  again  took  quinine  until  the 
constitutional  effects  were  produced,  the  dose  finally  reached  being  twenty  to 
twenty-five  grains,  which  was  taken  every  other  day.  While  employing  the 
quinine  in  this  manner  a  severe  attack  of  otitis  occurred.  The  patient  states 
in  a  written  history  taken  from  his  diary  that  he  recovered  from  the  otitis  under 
antiphlogistic  treatment. 

After  recovery  from  the  aural  disease,  Dr.  N was  obliged  to  resort  to  the 

use  of  the  quinine  on  account  of  the  constitutional  disease — a  severe  malarial 
neuralgia.  He  took  one  dose  of  fifteen  grains,  which  was  followed  by  pain  in 
the  ears.  Several  efforts  were  made  to  return  to  the  use  of  the  quinine,  but  pain 
in  the  ear  supervened  on  each  dose.  "From  this  period,  February,  1865,"  to 
quote  the  exact  words  of  the  patient,  "my  ears  began  to  give  me  constant  trouble. 
I  was  incessantly  annoyed  by  unnatural  noises,  which  would  frequently  reach 
such  a  pitch,  for  a  few  moments,  as  to  exclude  all  other  sounds."  The  naso- 
pharyngeal  disease  also  increased,  and  in  March,  1865,  he  was  seen,  on  account 
of  the  state  of  his  ears,  by  a  distinguished  practitioner.  The  throat  was  consid- 
ered the  origin  of  the  aural  affection,  and  it  was  accordingly  treated,  and  was 
improved  ;  but  the  ears  remained  in  the  same  condition,  that  is,  they  were  sensi- 
tive and  affected  by  tinnitus,  and  there  was  some  impairment  of  hearing. 

After  the  pharynx  had  been  treated,  until  July  of  this  year  (1865),  and  while 
undergoing  treatment,  another  attack  of  otitis  media  occurred,  which  was  pre- 
ceded by  five  weeks  of  facial  neuralgia.  The  use  of  quinine  for  the  relief  of 
these  attacks  had  been  avoided  ;  but  at  last,  the  patient,  worn  out  by  pain,  took 
a  fifteen-grain  dose  of  the  sulphate,  upon  which  the  ear  disease  immediately 
supervened.  The  quinine  was  taken  on  July  30th,  and  the  attack  of  otitis  media 
occurred  on  the  next  day.  The  otitis  was  of  so  severe  a  character  as  to  place  the 
doctor  in  a  very  depressed  condition,  and  when  he  recovered  from  this  and  the 
neuralgia,  which  he  did  simultaneously,  to  use  the  patient's  own  language,  he 
was  "a  perfect  wreck." 

1  Transactions  of  the  American  Otological  Society,  1873. 


172  EFFECTS   OF   QUININE. 

He  then  sailed  for  Europe,  and  in  the  Scotch  Highlands  recovered  from  the 
malarial  disease,  never  having  suffered  from  it  since  up  to  the  present  time.  The 
ears,  however,  became  very  sensitive  to  the  air,  and  cotton  plugs  were  resorted 

to,  and  Dr.  N lias  never  from  this  time  been  able  to  leave  the  meat  us  open, 

even  while  in-doors,  until  the  past  week.  The  hearing  power  was  also  greatly 
impaired  while  in  Scotland ;  the  patient  therefore  went  to  the  south  of  France, 
where  his  ears  were  still  troublesome.  The  aural  symptoms  were  tinnitus,  a 
sense  of  pressure  in  the  auditory  canal,  and  frequent  attacks  of  neuralgia  oi  the 
fifth  pair.  The  intellect  also  became  somewhat  obscured.  After  a  year's  stay 

abroad,  Dr.  N returned  home,  when  the  naso-pharyngeal  catarrh  returned. 

He  then,  under  the  advice  of  a  physician,  began  the  use  of  the  nasal  douche  for 
its  relief,  taking  all  the  precautions  that  are  enjoined,  using  a  warm  solution  of 
common  salt  in  water.  It  was  observed,  however,  that  in  an  hour  or  two  after 
using  the  douche,  there  was  an  uncomfortable  sensation  in  the  ears  which  became 
more  prominent  after  each  application.  The  physician  then  advised  "less  press- 
ure "  in  the  use  of  the  douche ;  but  the  next  application  was  followed  by  severe 
pain,  and  this  method  of  treatment  was  abandoned.  The  patient  was  then  suffer- 
ing from  what  was  called  an  inflammation  of  the  auditory  canal ;  all  treatment 
was  given  up  until  September  of  this  year,  when  another  attack  of  otitis  media 
and  of  facial  neuralgia  occurred.  The  next  two  years  were  spent  in  Italy. 

The  general  health  of  the  patient  was  then  excellent,  but  the  healing  did  not 
improve,  and  the  patient  was  obliged  to  use  the  cotton  plugs.  Returning  to 
America  in  the  spring,  the  naso-pharyngeal  catarrh,  which  had  not  appeared 
while  in  Italy,  returned,  and  in  April,  pain  occurred  in  both  ears,  for  which  he 
was  treated  by  leeches,  diaphoretics,  and  hot  fomentations ;  after  this  attack  the 
patient  describes  himself  as  totally  deaf — unable  to  distinguish  the  loudest 
sounds.  "  There  was  a  feeling  of  spasmodic  constriction,  and  fulness  invading 
the  cavity  of  the  tympanum,  and  a  sensation  of  pressure  upon  the  drum-head." 
On  the  third  day  the  patient  became  able  to  hear  what  was  said  to  him,  if  the 
words  were  spoken  very  loudly  and  with  the  mouth  applied  close  to  the  ear ;  as 
time  passed  he  became  still  more  improved,  so  that  he  could  hear  conversation 
addressed  specially  to  him  at  a  short  distance,  and  a  watch  usually  heard  at  four 
feet,  at  a  distance  of  two  inches  on  each  side,  H.  =  -&. 

This  was  his  condition  when  he  first  came  under  my  observation,  on  May  3, 

1870.     I  found  that  the  general  nervous  system  of  Dr.  N ,  from  his  years 

of  suffering,  was  in  a  highly  sensitive  condition.  His  pharynx  was  highly  con- 
gested, the  uvula  very  long,  and  both  auditory  canals  were  extremely  sensitive 
and  plugged  with  hard  wax.  For  two  weeks  the  patient  was  under  my  care, 
during  which  time  I  cut  off  the  uvula,  and  made  many  attempts  to  remove  the 
impacted  wax  by  syringing,  and  the  use  of  the  forceps  ;  but  in  all  these  attempts 
I  failed,  in  consequence  of  the  hardness  of  the  cerumen  and  the  tightness  with 
which  it  was  held  by  the  auditory  canal,  and  also  because  the  ear  was  extremely 
tender  to  the  slightest  touch. 

•  At  the  end  of  this  time,  the  patient  was  suddenly  called  to  Minnesota,  and  I 
did  not  see  him  again  until  June  26,  1872,  when  he  presented  himself  and  gave 
the  following  history  of  the  time  that  had  elapsed.  The  very  small  quantity  of 
wax  removed,  and  the  cutting  off  of  the  uvula,  had  relieved  the  pharynx  and  ears 
to  some  slight  extent,  and,  the  climate  being  adapted  to  his  condition,  he  did 
very  well,  except  that  the  hearing  was  impaired. 

On  June  18,  1871,  another  attack  of  otitis  occurred,  which  caused  some  con- 


INSPISSATED   CERUMEN.  173 

siderable  discomfort,  although  it  was  a  less  severe  attack  than  those  which  had 
preceded  it.  The  otitis  again  occurring,  the  patient  came  to  me,  on  the  date 
above  mentioned;  more  than  two  years  from  the  first  visit.  I  found  him  suffering 
severe  pain,  for  which  he  was  taking  anodynes  ;  the  ears  were  about  in  the  same 
state  as  when  I  last  saw  him.  The  hearing  distance  was  about  -4%,  the  canals  were 
plugged  with  hardened  wax ;  the  patient  appeared  in  fair  physical  condition,  but 
mentally  he  was  excited  and  slightly  irritable  and  depressed. 

I  proceeded  to  remove  the  impacted  wax,  and  that  from  the  right  ear  came 
away  on  the  second  day.  It  was  so  tightly  wedged  in  that  the  removal,  which 
was  effected  by  the  syringe  and  forceps,  caused  severe  pain,  although  the  walls 
of  the  canal  were  not  touched.  On  the  fifth  day,  after  the  use  of  vaiious  agents 
to  soften  the  mass  of  cerumen  in  the  left  ear,  I  burned  it  with  nitric  acid,  and 
then  succeeded  in  removing  it.  This  removal  also  caused  great  pain.  The 
meinbranse  tympani  were  suppurating,  that  is,  the  outer  layers,  and  they  were 
somewhat  sunken,  especially  along  the  handle  of  the  malleus.  The  use  of  a 
solution,  nitrate  of  silver  40  gr.  ad  §  ]'.,  and  inflation  by  Politzer's  method,  soon 
restored  them  to  a  normal  appearance,  except  that  the  curvature  remained  al- 
tered. The  sensitiveness  of  the  ears  was  removed,  so  that  they  could  be  touched, 
applications  made  to  the  drum-head,  and  so  on,  without  producing  any  unpleas- 
ant sensations.  The  hearing  distance  became  -4ag-  on  the  right  side,  and  was  im- 
proved on  the  left,  but  to  what  extent  I  do  not  know,  not  having  seen  the  patient 
for  some  time.  He  became  able  to  sleep  without  an  anodyne.  The  cotton  plugs 
which  had  been  worn  for  years  were  now  removed,  and  he  became  altogether  a 
different  person,  as  regards  his  mental  condition. 

I  think  we  must  regard  the  otitis  in  this  case,  although  to  a 
certain  extent  dependent  upon  the  naso-pharyngeal  catarrh,  as 
chiefly  caused  by  the  use  of  quinine.  By  looking  at  the  history, 
and  observing  how  promptly  and  invariably  the  pain  in  the  ears 
occurred  in  several  instances  after  the  use  of  the  agent,  we  are 
forced  to  the  conclusion  that  quinine  was  the  exciting  cause  of 
the  aural  inflammation.  At  what  date  the  impaction  of  wax 
occurred,  we  cannot  positively  determine.  I  am  disposed  to  be- 
lieve that  it  was  at  the  time  the  patient  awoke  profoundly  deaf. 
in  April,  1870,  or  more  than  two  years  before  it  was  removed. 
The  wax  was  certainly  there  one  month  after,  in  May,  1870,  when 
I  first  saw  him. 

The  condition  of  the  patient's  mind  is  illustrated  by  the  fact 
that  he  allowed  two  years  to  pass  away  with  no  attempt  to 
remove  a  foreign  body,  from  whose  partial  removal  he  had  ob- 
tained some  relief,  and  which  he  believed  to  be  one  of  the  causes 
of  his  impaired  hearing.  I  can  only  partially  account  for  this 
delay,  by  supposing  that  my  efforts  at  softening  and  removing 
the  mass  had  so  far  succeeded  as  to  lift  the  cerumen  from  the 
drum-head,  and  thus  gave  partial  relief.  Indeed,  the  plug,  which 
I  took  out  on  the  second  day,  was  on  its  way  out,  and  would,  I 
think,  have  soon  escaped  spontaneously,  with  one  of  the  loud 


174  INSPISSATED   CERUMEN — CASES. 

reports  with  which  hardened  wax  sometimes  shoots  from  the 
auditory  canal.  The  structure  of  the  plugs  was  that  usually 
found,  that  is,  cerumen  in  layers  ;  but  there  was  some  epidermis 
exfoliated,  and  also  some  pus  between  the  mass  of  wax  and  the 
canal. 

The  case  seems  to  me  to  be  one  of  those  which  have  been 
reported,  where  inflammation  of  the  integument  lining  the  canal 
was  one  of  the  causes  of  impaction  of  wax,  and  it  may  be  a  con- 
tribution to  the  etiology  of  that  disease.  The  earlier  history  also 
illustrates  the  effect  of  quinine  upon  the  ear,  which  I  believe  is 
sometimes  an  inflammation  of  the  conducting  portions,  as  well 
as  of  the  acoustic  nerve  or  labyrinth.  We  have  long  suspected 
the  latter  effect,  but  the  former  has  not  been  often  observed. 

The  following  case  occurred  in  my  clinic  at  the  Brooklyn  Eye 
and  Ear  Hospital,  and  was  reported  by  Dr.  David  Webster, '  who 
was  then  House  Surgeon. 

It  illustrates  the  serious  inflammatory  trouble  that  may  be 
,caused  by  inspissated  cerumen,  a  fact  which  has  been  already 
alluded  to  in  this  chapter,  for  there  is  no  doubt  in  my  mind,  that 
while  the  impaction  of  cerumen  is  sometimes  caused  by  inflam- 
mation, that  it  in  turn  may  produce  ulceration — by  mechanical 
pressure. 

CASE  VI. — Pain — Tinnitus — Deafness — Inspissated  Cerumen — Suppuration  of 

the  Canal — Incisions — Recovery. — D.  H ,  aged  28,  laborer,  presented  himself 

at  Dr.  Roosa's  clinic,  at  this  hospital,  November  1,  1870.  Five  days  previously 
his  right  ear  was  attacked  with  pain,  tinnitus,  and  deafness,  which  symptoms 
had  gradually  increased  up  to  date.  He  had  slept  but  little  for  the  last  two 
nights,  in  consequence  of  the  severity  of  the  pain.  He  could  hear  the  ticking  of 
an  ordinary  watch  at  the  distance  of  only  one  inch. 

Upon  examination  we  observed  a  little  pufflness  of  mastoid  process,  and  some 
swelling  back  of  the  angle  of  the  lower  jaw  and  of  the  walls  of  the  meatus. 
There  was  also  some  pharyngitis.  Through  the  aural  speculum  the  external 
meatus  was  seen  to  be  plugged  with  hard  wax.  This  was  removed  by  carefully 
syringing  the  ear  with  warm  water.  Some  pus  was  found  in  the  canal,  and  at 
first  the  membrana  tympani  was  thought  to  be  perforated,  but  upon  more  care- 
ful examination  it  was  found  to  be  intact,  though  a  complete  examination  of  it 
was  rendered  impossible  by  the  narrowing  of  the  meatus  consequent  upon  the 
swelling. 

Politzer's  method  for  inflating  the  middle  ear  was  practised,  and  the  patient 
was  directed  to  fill  his  ear  frequently  with  warm  water. 

November  2d. — He  said  that  the  pain  was  so  relieved  that  he  rested  well 
last  night,  and  complained  more  of  a  sensation  of  soreness  than  of  pain.  The 
tinnitus  and  swelling  were  undiminished,  but  the  hearing  distance  had  risen  to 
ten  inches.  On  using  Politzer's  method,  the  patient  felt  the  air  enter  neither 

1  Medical  Record,  vol.  v.,  p.  536. 


INSPISSATED   CERUMEN — CASES.  175 

ear,  and  when  this  was  done  again,  with  the  addition  of  the  vapor  of  chloro- 
form, the  air  was  felt  only  in  the  left.  He  was  directed  to  continue  the  use  of 
warm  water. 

November  3d. — The  swollen  walls  of  the  meatus  had  become  more  sensitive 
to  the  touch,  and  the  pain  had  returned.  He  was  treated  by  means  of  the  warm 
aural  douche,  Politzer's  method  again  used,  and  the  entrance  to  the  meatus 
stuffed  with  cotton  in  order  to  exclude  the  cold  air. 

November  5th. — The  swelling  had  increased.  Dr.  Prout,  who  saw  the  pa- 
tient for  Dr.  Koosa,  made  two  incisions  in  the  walls  of  the  meatus — one  back- 
ward, the  other  upward.  Pus  followed  the  knife  in  the  latter.  The  pain  caused 
by  the  incisions  was  immediately  relieved  by  the  warm  douche  (Clarke's  aural 
douche). 

Dr.  F.  M.  Pierce,1  of  Manchester,  England,  reported  a  case 
where  the  symptoms,  arising  apparently  from  inspissated  ceru- 
men, were  more  severe  than  any  I  have  ever  seen  in  my  prac- 
tice, yet  from  the  severity  of  cases  which  I  have  seen,  I  can 
well  imagine  Dr.  Pierce's  case. 

Four  days  before  Dr.  Pierce  saw  the  patient — a  chemist,  age  not  stated — he 
had  a  severe  earache  after  taking  a  cold  bath,  which  soon  became  a  diffused  in- 
cessant pain  over  the  whole  head  and  neck,  with  nausea,  vomiting,  and  fever. 
His  case  was  regarded  as  one  of  cerebral  inflammation  until  the  fifth  day  of  his 
illness,  when  Dr.  Pierce  saw  him  and  examined  the  ears.  The  watch  was  not 
heard  on  that  side,  while  a  tuning-fork  placed  on  the  head  was  heard  only  on 
that  side.  The  walls  of  the  canal  were  swollen  and  congested,  and  there  was 
impacted  wax.  This  was  removed  piecemeal  by  the  forceps,  syringe,  and  a  warm 
lotion  was  dropped  into  the  ear.  The  next  day  the  patient  was  free  from  pain, 
fever,  and  nausea,  and  he  could  hear  the  watch  two  inches.  After  syringing  the 
ear  (clearing  out  the  remains  of  the  wax  ?),  the  watch  was  heard  thirty-six  inches, 
and  the  patient  fully  recovered. 

Dr.  Pierce  suggests,  and  I  suppose  the  reader  will  agree  with 
him,  that  the  cold  water  in  the  canal  set  up  a  diffuse  inflamma- 
tion, which  was  favored  by  the  presence  of  a  hard  foreign  body, 
which  was  probably  not  fully  impacted  when  the  water  got  into 
the  ear,  but  which  became  so,  and  increased  the  inflammatory 
symptoms. 

In  many  cases  it  will  be  necessary  to  treat  the  auditory  canal, 
after  the  removal  of  the  wax,  for  a  diffuse  inflammation.  I 
then  use  a  solution  of  nitrate  of  silver  of  say  twenty  grains  to 
the  ounce,  pencilling  it  upon  the  canal,  especially  at  the  junc- 
tion of  the  cartilaginous  with  the  osseous  portion,  every  other 
day,  until  the  normal  condition  is  restored. 


Medical  Times  and  Gazette,  March  30,  1878. 


176  INSPISSATED   CERUMEN. 


STATISTICS. 

Two  hundred  and  thirty-one  of  the  497  cases  mentioned  on 
page  158  as  treated  by  me  in  private  practice,  were  plainly  also 
affected  with  other  diseases  of  the  ear,  as  follows  : 

Chronic  catarrh  of  the  middle  ear 120 

Subacute  catarrh  of  the  middle  ear 20 

Chronic  proliferous  inflammation  of  the  middle  ear 24 

Chronic  suppuration  of  the  middle  ear 19 

Inflammation  of  the  external  auditory  canal 16 

Eczema 9 

Foreign  body 1 

Parasitic  inflammation  of  the  external  ear 1 

Acute  catarrhal  inflammation  of  the  middle  ear 5 

Disease  of  acoustic  nerve 9 

Other  complications 7 

231 

It  will  be  seen  that  about  one-third  of  the  cases  seen  in  my 
private  practice  were  plainly  accompanied,  if  not  caused,  by 
aural  inflammation.  I  am  bound  to  say,  that  this  proportion 
would  have  been  largely,  increased,  had  I  earlier  in  my  practice 
given  as  much  attention  to  the  study  of  inspissated  cerumen  as 
I  now  do.  It  was  easy,  especially  when  the  patients  who  were 
relieved  by  the  removal  of  a  large  plug  of  cerumen  said  they 
heard  perfectly,  "had  no  more  trouble,"  were  "in  a  new  world," 
and  so  forth,  to  conclude  that  their  delight  at  their  recovery 
from  the  fulness,  pain,  and  impairment  of  hearing  was  founded 
upon  a  complete  cure  of  the  aural  lesion.  A  little  more  thorough 
examination  often  shows,  however,  that  the  wax  is  but  the  most 
striking  symptom  of  an  insidious  process  that  will  finally,  unless 
checked,  destroy  all  useful  hearing  power. 

The  case  of  recurrent  attacks  of  inspissated  cerumen  related  on  page  170  is 
by  no  means  a  very  uncommon  one,  although  not  in  as  aggravated  a  condition 
as  the  one  there  described.  A  patient  once  having  inspissated  cerumen,  is  very 
apt  to  have  a  recurrence  of  the  affection. 

COMPOSITION  AND  FUNCTIONS  OF  CERUMEN. 

According  to  J.  E.  Petrequin,1  cerumen  is  of  a  smeary  con- 
sistency, on  account  of  the  soapy  material  made  by  the  potash 

1  Archiv  fiir  Ohrenheilkunde,  Bd.  V.,  p.  230,  from  Comptes  Rend,  de  1'Acad.  des 
Sciences,  xvi.,  pp.  940,  941.   1869. 


COMPOSITION   OF   CERUMEN.  177 

which  it  contains.  A  part  of  it  is  soluble  in  water,  another  in 
water  and  alcohol.  It  also  contains,  according  to  the  same  au- 
thority, about  one-tenth  per  cent,  of  water,  a  mixture  of  oil  and 
stearine,  and  a  dry  material  not  soluble  in  water,  alcohol,  and 
ether,  in  which  potash,  and  traces  of  chalk  and  soda  are  found. 
A  s  age  advances,  the  parts  of  the  cerumen  that  are  soluble  in 
water  and  soluble  substances  increase,  but  those  soluble  in  cilco- 
hol  diminish  ;  so  that  in  older  persons  the  cerumen  becomes  dry 
and  brittle. 

Kessel's  account  of  the  cerumen  is  as  follows  '  :  The  contents 
of  the  ceruminous  glands  only  differ  from  those  of  the  sw^eat 
glands  in  the  fact  that  the  former  contain  masses  of  very  fine 
coloring  matter.  The  substance  secreted  by  the  ceruminous  and 
sebaceous  glands  together,  is  a  yellowish -white,  rather  fluid 
material,  which  consists  essentially  of  small  and  large  fat  glob- 
ules, corpuscles  of  coloring  matter  in  masses,  and  cells  in  which 
single  globules  of  fat  and  coloring  matter  are  embedded  ;  hairs 
and  scales  of  epidermis  from  the  lining  of  the  canal  are  also 
found  in  the  canal. 

Those  who  are  curious  in  regard  to  the  opinions  of  the  last 
century  and  the  early  part  of  the  present  one,  on  the  subject  of 
the  functions  of  the  cerumen  and  the  affections  of  the  ear  caused 
by  the  suppression  of  the  secretion,  will  find  the  book  of  Thomas 
Buchanan,2  of  Hull,  interesting  reading.  Mr.  Buchanan  ascribed 
most  of  the  diseases  of  the  ear  to  impactioii  of  cerumen  or  stop- 
page of  its  secretion.  He  believed  that  it  had  a  very  important 
function  in  relieving  the  harshness  of  the  waves  of  sound.  If  it 
were  not  for  the  lining  of  cerumen  which  is  in  the  meatus,  the 
waves  of  sound  would  fall  irregularly  upon  the  drum  membrane 
and  cause  it  to  vibrate  unevenly.  Mr.  Buchanan  also  explained 
Mr.  Everard  Home's  case  of  double  hearing  by  his  theory  of  defi- 
cient secretion  of  the  cerumen.  It  wras  that  of  a  music  teacher, 
who  found  that  after  a  cold  the  pitch  of  one  ear  was  half  a  note 
deeper  than  the  other,  and  that  a  simple  tone  was  not  recognized 
as  one  by  both  ears.  This  is  a  specimen  of  the  author's  fanciful 
notions  about  the  important  functions  of  this  lubricating  and 
protecting  secretion. 

1  Strieker's  Manual :   The  External  Ear,  by  Kessel,  translated  by  J.  Orne  Green, 
p.  951. 

2  Physiological  Illustrations  of  the  Organ  of  Hearing,  more  particularly  of  the  Secre- 
tion of  Cerumen,  and  its  effects  in  rendering  auditory  perception  accurate  and  acute, 
with  further  remarks  on  the  treatment  of  diminution  of  hearing,  arising  from  im- 
perfect secretion,  etc.     Being  a  sequel  to  the  Guide  and  to  the  Illustrations  of  Acoustic 
Surgery.     London,  1828. 

12 


178  INSPISSATED   CERUMEN 

He  makes  a  disease — Tubulus  Hirsutus — of  the  growth  of 
hairs  in  the  canal,  saying  that  no  one  with  acute  hearing  has 
hairs  growing  over  the  surface  of  the  membrana  tympani.  He 
also  tells  a  singular  story  of  a  man  who  became  very  deaf,  in  his 
opinion  from  years  of  loud  talking  to  a  deaf  wife.  He  imagined 
that  the  continued  screaming  at  last  lessened  the  sensibility  of 
theportio  mollis.1 

The  function  of  the  ceruminous  glands,  is  probably  that  of  the 
sudoriparous  glands.  They  keep  the  parts  in  which  they  secrete 
pliable,  and  also  prevent  the  ready  admission  of  insects.  There 
is  no  evidence  that  the  cerumen  has  anything  to  do  with  the  reg- 
ulations of  the  intensity  with  which  the  waves  of  sound  reach 
the  ear. 

Hallucinations  have  been  in  rare  instances  relieved  by  the 
removal  of  inspissated  cerumen.  Professor  Mayer,  formerly 
director  of  the  Insane  Asylum  at  Hamburg,  is  the  authority  for 
this  statement." 

I  once  saw  a  lady  who,  though  not  regarded  as  a  person  of 
unsound  mind,  seemed  to  be  such,  and  who  complained  greatly 
of  tinnitus  aurium  in  all  its  varieties.  I  found  the  ears  full  of 
impacted  cerumen ;  but  she  utterly  refused  to  allow  me  to  remove 
it,  and  I  never  saw  her  but  once.  It  would  have  been  very  inter- 
esting to  know  the  effect  of  the  relief  of  the  tinnitus  upon  the 
hallucinations  of  which  she  seemed  to  be  a  victim.  Epilepsy  is 
said  to  have  been  cured  by  the  removal  of  hard  wax  from  the 
ear.  (See  page  205.)  Certainly  it  has  been  from  the  removal  of  a 
foreign  body.  It  will  be  seen,  by  reference  to  the  following 
chapter,  that  it  may  cause  ear  cough  and  ear  sneezing. 

1  A  good  synopsis  of  Buchanan's  book  will  be  found  in  Lincke's  Sammluug  aus- 
erlesener  Abhandlungen  und  Beobachtungen  aus  dem  Gebiete  der  Ohrenheilkunde, 
Bd.  IIL     Leipzig,  1836. 

2  Troltsch  on  the  Ear,  second  edition,  translation,  p.  531. 


CHAPTER  VIII. 

FOEEIGN  BODIES. 

Exaggeration  of  the  Importance  of  this  Subject. — Statistics. — Insects. — Living  Lar- 
vae.— Fish. — Inanimate  Foreign  Bodies. — Treatment. — Delusions  as  to  Foreign 
Bodies  in  the  Ear.  — Foreign  Bodies  in  the  Eustachian  Tube.  — Ear  Cough. 

IN  entering  upon  the  discussion  of  the  subject  of  foreign  bodies 
in  the  ear,  I  desire  to  express  the  conviction  that  its  impor- 
tance has  been  often  exaggerated.  The  reader  of  medical  jour- 
nals, who  has  not  given  any  special  attention  to  diseases  of  the 
ear,  must  be  surprised  to  find  this  subject  figuring  so  largely  in 
literature,  when  he  knows  that  the  general  practitioner  of  large 
experience  sees  but  very  few  of  such  cases,  even  if  he  lives 
remote  from  specialists  and  surgical  experts.  The  reports  of 
hospitals  and  infirmaries  for  diseases  of  the  eye  and  ear  also 
show  that  the  entrance  of  a  foreign  body  into  the  auditory  canal 
is  brought  to  the  attention  of  the  attending  surgeons  with  com- 
parative infrequency. 

The  following  table  shows  this  : 

Total  number    Number  of  cases 

of  aural  of  foreign 

cases.  bod}-. 

Manhattan  (New  York)  Eye  and  Ear  Hospital,  20  years,  20,103  130 

New  York  Eye  and  Ear  Infirmary,  1889 3, 738  49 

New  York  Ophthalmic  and  Aural  Institute,  1889 983  10 

Brooklyn  Eye  and  Ear  Hospital,  21  years 23,729  309 

Massachusetts  Eye  and  Ear  Infirmary,  1889 3,952  19 

Salem  Hospital,  15  years 1,276  21 

St.  Michael's  Hospital  (Newark,  N.  J.),  1888 615 

Newark  Eye  and  Ear  Infirmary,  1889 1,296  13 

Illinois  Eye  and  Ear  Infirmary,  1885-1886 1,971 

Buffalo  Eye  and  Ear  Infirmary,  1889 171 

57,834  562 

i 

In  the  Manhattan  Eye  and  Ear  Hospital,  for  twenty  years. 
130  cases  of  foreign  bodies  in  the  ear  have  been  presented  for 


180  FOREIGN   BODIES. 

treatment,  and  2  of  supposed  foreign  body.  In  my  private  prac- 
tice in  4800  cases  there  were  2G  of  foreign  bodies,  and  4  in  which 
the  patient  or  friends  supposed  there  was  one,  and  yet  none  was 
found.1  These  statistics  show  that  foreign  bodies  in  the  ear,  are 
not  as  frequently  seen  by  the  surgeon,  as  the  inexperienced  prac- 
titioner might  be  led  to  suppose. 

But  my  opinion  that  the  importance  of  the  subject  has  been 
exaggerated,  by  the  great  mass  that  has  been  written  upon  it, 
is  not  founded  altogether  upon  the  relative  infrequency  of  the 
cases.  If  cases,  that  are  comparatively  uncommon,  are  still  very 
dangerous,  in  nearly  every  instance  when  they  do  occur,  the 
medical  teachers  have  a  right  to  call  attention  to  them  as  being 
very  important  and  to  dwell  upon  them,  even  at  the  risk  of 
wearying  their  listeners  and  readers.  But  foreign  bodies  in  the 
auditory  canal  as  a  rule,  are  not  dangerous.  In  this  respect  they 
have  none  of  the  importance  of  foreign  bodies  within  the  eyeball. 
Foreign  bodies  in  the  tympanic  cavity,  are  necessarily  dangerous 
and  destructive  to  the  functions  of  the  ear,  but  in  the  vast  major- 
ity of  cases  of  foreign  bodies  in  the  ear,  the  foreign  body  is  this 
side  of  the  drum-head. 

This  much  is  said  by  way  of  introduction,  with  the  hope 
that  it  will  enable  the  practitioner  who  may  consult  these 
pages,  to  enter  upon  the  management  of  a  case  of  foreign 
body  in  the  ear,  when  it  comes  to  him,  with  coolness  and  with- 
out fear  that  he  has  one  which  will  brook  no  delay,  and  which 
will  tolerate  no  mere  palliative  means,  without  danger  to  the 
hearing  or  the  life. 

'  The  usual  point  of  entrance  of  foreign  bodies  into  the  ear, 
is  through  the  external  auditory  canal.  They  sometimes  pass 
beyond  this  part  and  become  lodged  in  the  cavity  of  the  tym- 
panum, or  Eustachian  tube,  while  in  some  rare  instances  a  for- 
eign body  has  entered  the  ear  through  the  Eustachian  tube.  I 
have  therefore  entitled  this  chapter  "Foreign  Bodies,"  so  that 
I  might  properly  include  all  such  cases  in  the  descriptions  that 
are  about  to  be  given. 

The  foreign  bodies  that  are  found  in  the  auditory  canal,  are 
very  naturally  placed  under  three  heads  :  insects,  or  the  like, 
which  creep  into  the  passage  ;  their  larvae,  which  are  generated 
there  ;  and  various  articles,  such  as  beads,  buttons,  peas,  beans, 
and  so  on,  which  are  pushed  into  the  ear  by  children  or  silly 
adults,  or  which  may  be  thrown  into  the  ear. 

1  Buckner's  statistics,  made  up  from  various  authorities,  show  that  of  a  total  of 
43,730  cases,  670  were  cases  of  foreign  bodies.  Archiv  fiir  Ohrenheilkunde,  1883. 


INSECTS. 


INSECTS. 

When  a  live  insect  gets  into  an  ear,  the  pain  produced  is 
usually  intense  and  agonizing.  Insects  are  more  apt  to  get  into 
the  ears  of  sportsmen  while  hunting  in  thicket  and  underbrush, 
and  of  farmers  laboring  in  the  field,  than  of  dwellers  in  cities 
and  towns.  Yet,  on  the  hot  days  of  summer,  when  insect  life 
is  very  active,  the  city  practitioner  will  sometimes  be  called  to 
remove  a  bug  from  the  ear,  if  the  agony  induced  by  the  foreign 
body  do  not  stimulate  some  of  the  family  to  a  successful  at- 
tempt at  its  removal. 

There  is  an  insect,  which  lives  on  the  leaves  of  fruits  and 
flowers,  and  which,  like  others,  sometimes  flies  into  the  ear, 
which  is  called  an  ear- wig,  and  there  was  an  ancient  supersti- 
tion that  it  crept  into  the  brain  through  the  ear.  The  forficula 
auricularis,  or  so-called  ear-wig,  has  probably  no  more  propen- 
sity to  fly  into  the  ear  than  any  other  insect ;  any  of  the  ordi- 
nary flies  may  do  so. 

I  have  seen  a  few  cases  of  cockroaches  in  the  ear,  as  well  as 
croton  bugs.  I  have  never  had  any  difficulty  in  removing  them. 
In  some  instances  they  die  in  the  ear,  and  then  they  become  the 
nucleus  for  the  collection  of  cerumen  about  them. 

The  most  efficient  and  the  speediest  means  of  removing  an 
insect  from  the  ear  is  the  use  of  a  syringe  and  warm  water.  As 
little  animals  usually  get  into  the  ear  when  the  patient  is  in  the 
fields  or  forests,  where  physicians  are  not  always  at  hand,  lay- 
men should  be  taught,  in  the  case  of  the  occurrence  of  such  an 
accident,  to  immediately  pour  water  or  any  bland  fluid  in  the 
meatus.  This  will  disturb  the  animal  and  either  drown  it  or 
cause  it  to  run  out. 

Some  writers  advise  the  use  of  an  oil  dropped  into  the  ear 
before  the  water  is  used,  but  Wilde  and  Troltsch  agree  that  this 
is  an  unnecessary  waste  of  time.  In  all  the  cases  I  have  treated, 
the  insect  was  promptly  dislodged  by  the  use  of  the  syringe,  and 
I  have  no  doubt  that  the  simple  filling  of  the  auditory  canal 
with  water,  will  cause  insects  to  come  out  at  once. 

LIVING  LARVAE  IN  THE  EAR. 

Insects  sometimes  deposit  their  eggs  upon  the  pus  of  a  sup- 
purating ear.  According  to  Wood,  who  is  quoted  by  Blake,1 
insects  have  a  very  acute  sense  of  smell.  "No  flock  of  vul- 

1  Living  Larvae  in  the  Human  Ear.  Archives  of  Ophthalmology  and  Otology,  VoL 
II.,  No.  2. 


182  LIVING  LARVAE. 

tures  can  be  directed  more  unerringly  to  their  revolting  prey  by 
scenting  its  odors  from  afar." 

The  odor  of  an  otitis  media  purulenta,  thus  brings  the  insect 
to  deposit  its  eggs  in  the  auditory  canal  and  cavity  of  the  tym- 
panum, where  they  soon  become  grubs  or  larvae. 

These  larvee  always  excite  considerable,  and  sometimes  very 
severe  pain,  but  in  the  cases  which  I  have  seen,  the  patients 
complain  much  more  of  the  wriggling  movements  of  the  grubs 
in  the  ear,  than  of  the  pain. 

The  ancient  works  on  aural  diseases  speak  very  much  of 
worms  in  the  ear  and  of  the  proper  means  of  removing  them. 
It  is  probable,  that  these  so-called  worms,  were  the  larvae  of 
insects  wfyich  germinated  from  eggs  deposited  in  the  pus  of  a 
chronic  suppurative  process.  Certain  it  is,  that  the  practitioner 
of  the  present  time,  sees  very  little  of  worms  in  the  ears,  since 
the  habit  of  cleansing  an  ear  from  pus,  has  become  a  well- 
recognized  duty.  The  pain  from  the  presence  of  these  grubs, 
which  actually  fasten  themselves,  when  hatched,  into  the  tissue 
of  the  canal,  and  bite  upon  it,  as  it  were,  is  apt  to  occur  sud- 
denly. An  Austrian  physician,  Dr.  Scheibenzuber,1  reports  a 
case  of  a  peasant  ploughing  in  the  field,  who  was  seized  in  an 
instant,  with  a  severe  pain  in  the  ear,  which  he  ascribed  to  the 
flying  in  of  a  bug,  but  the  surgeon  found  the  ear  full  of  well- 
developed  larvae. 

I  have  several  times  observed  dead  insects,  in  the  pus  that 
was  washed  out  from  an  external  auditory  canal,  and  it  is  un- 
doubtedly true,  as  I  have  already  suggested,  that  we  should, 
equally  with  the  ancients,  have  many  cases  of  living  larvae  in 
the  ear,  were  it  not  that  suppurating  ears  are  usually  now- 
a-days  regularly  cleansed. 

The  larvae  that  have  thus  -far  been  found  in  the  ear  are  those 
of  the  muscida  sarcophaga  (Blake,  Gruber),  and  of  the  muscida 
lucilia  (Blake).  Dr.  Blake *  has  made  a  study  of  the  nature  and 
habits  of  these  grubs,  by  taking  them  from  the  ear  at  a  very 
early  period  of  development ;  as  near  as  could  be  ascertained 
within  twelve  hours  of  the  time  of  their  deposit.  He  placed  a 
specimen  on  the  bottom  of  a  thin  glass  vessel,  and  covered  it 
with  a  piece  of  raw  beef,  soaked  in  warm  water,  in  such  a  man- 
ner that  by  inverting  the  glass  the  movements  of  the  larvae 
could  be  easily  studied  under  the  microscope.  Dr.  Blake  found 
that  the  apparatus  by  which  the  larva  attaches  itself,  and  which 
pierces  and  tears  the  tissue,  is  made  up  of  a  strong  but  delicate 

1  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  Xo.  3. 
*  Archives  of  Ophthalmology  and  Otology,  loc.  cit. 


LIVING   LARV.E.  183 

framework  of  horny  consistency  and  of  two  hooks  also  of  a 
stout  horny  structure,  articulating  with  this  framework.  The 
larva  burrows  its  way  into  the  tissue  on  which  it  feeds  by  re- 
peated extension  and  contraction  of  the  hooks,  alternately  pierc- 
ing and  tearing.  These  movements  explain  the  agonizing  pain 
which  patients  experience  when  the  larvae  appear  from  the 
eggs.  These  hooks  are  very  large  in  proportion  to  the  size  of 
the  body  of  the  larvae. 

Dr.  Blake  says  that  the  instincts  of  the  animal  lead  it  to  bury 
itself  beneath  the  surface,  and  to  seek  warmth  and  moisture 
and  a  soft,  yielding  tissue  for  its  work.  Hence  they  are  always 
found  at  the  end  of  the  canal,  or  in  the  cavity  of  the  tympanum. 
As  yet,  they  have  always  been  found  in  connection  with  sup- 
puration of  the  middle  ear,  with  its  consequent  perforation  of 
the  membrana  tympani. 

The  examination  of  the  auditory  canal  infested  by  living 
larvae,  shows  small  white  worm-like  animals  moving  rapidly 
about,  very  much  as  a  mass  of  common  earth-worms.  As  I 
write,  I  have  before  me  a  number  of  specimens  of  the  dead 
grubs.  They  are  about  half  an  inch  in  length,  and  of  the 
diameter  of  a  large  knitting-needle. 

Dr.  Gruening  reported  at  a  meeting  of  the  New  York  Oph- 
thalmological  Society,  in  1882,  a  case  of  living  larvae  in  the 
auditory  canal  when  the  tissues  were  sound,  but  his  case  is  as 
yet  unique  in  literature,  I  believe. 

Very  small  fish,  have  been  known  to  enter  the  auditory  canal 
while  the  victim  was  bathing.  One  of  my  patients,  a  lady,  gave 
me  a  minute  account  of  such  an  occurrence  to  herself.  The 
little  intruder  caused  great  pain  for  some  hours,  and  finally 
came  out  spontaneously.  In  the  Reading  (Pa.)  Eagle  of  July  9, 
1880,  there  is  a  circumstantial  account  of  a  case  of  the  entrance 
of  a  fish  two  inches  long,  into  the  ear  of  a  boy  of  fourteen,  while 
he  was  bathing.  According  to  this  account,  he  suffered  for 
two  weeks  from  intermittent  and  severe  pain.  As  his  parents 
thought  it  was  "only  an  earache,"  no  physician  was  called. 
Laudanum,  rabbits'  fat,  and  molasses  were  among  the  remedies 
used  for  the  two  weeks  that  the  boy  was  suffering  intolerable 
pain,  which  greatly  reduced  his  strength.  The  mother  of  the 
boy,  finally,  in  one  of  his  fits  of  pain,  wound  a  handkerchief 
around  the  head  of  a  pin  and  probed  the  ear.  "  She  saw  some- 
thing protrude,"  and  got  hold  of  it  and  pulled  it  out,  when  it 
proved  to  be  a  living  fish  of  the  length  above  stated.  The  lady 
who,  while  she  was  under  my  care  for  aural  affection  of  another 
kind,  told  me  of  her  sufferings  from  the  entrance  of  a. small  fish 
into  the  auditory  canal,  also  said  that  the  pain  was  so  decidedly 


184  LIVING   LAEVzE. 

intermittent  in  character,  she  being  for  some  hours  at  a  time 
without  pain,  that  she  could  not  believe  anything  animate  in 
her  ear  was  causing  the  trouble. 

Treatment. — I  have  found  it  impossible  to  remove  living  larva? 
by  means  of  the  syringe.  The  more  they  are  syringed  the  more 
lively  they  become.  Before  the  syringing  is  attempted,  some 
agent  should  be  instilled  into  the  ear  which  will  kill  them,  when 
the  syringe  will  usually  remove  them.  Sometimes,  however, 
even  after  death,  their  hooks  penetrate  so  deeply  into  the  tissue 
that  they  can  only  be  removed  with  the  forceps.  The  forceps 
should  not  be  needlessly  used,  however,  for  even  with  the  most 
careful  manipulation,  and  with  tractable  patients,  they  often 
abrade  the  integument  of  the  canal,  and  thus  cause  pain.  I 
have  used  Labarraque's  solution  of  chlorinated  soda,  to  kill  these 
grubs,  but  simply  because  it  was  at  hand  when  I  saw  the  cases. 

The  larvse  have  also  been  killed  by  forcing  the  vapor  of 
chloroform  into  the  cavity  of  the  tympanum  through  the  Eusta- 
chian  tube.  I  believe,  however,  that  it  will  be  sufficient  to  force 
the  vapor  into  the  external  ear,  or  to  instill  some  such  fluid  as  I 
have  mentioned  into  the  canal. 

It  need  hardly  be  said,  that  the  disease  which  allowed  of  the 
deposition  of  the  eggs,  and  the  hatching  of  the  grubs,  should  be 
treated  after  they  have  been  removed.  Even  those  who  are 
advocates  of  allowing  a  discharge  from  the  ear  to  remain  un- 
checked, will  hardly  defend  such  a  neglect  when  the  ear  has 
become  a  disgusting  receptacle  in  which  larvse  are  formed. 

INANIMATE   FOREIGN   BODIES. 

The  foreign  bodies  that  are  placed  in  the  ears  of  children  by 
themselves  or  their  playmates,  have,  from  the  time  of  the  first 
writers  on  otology,  formed  a  fertile  field  for  the  labors  of  sur- 
geons. From  some  source  or  other,  the  laity  have  got  the  im- 
pression that  a  foreign  body  in  the  ear,  like  a  wild  beast  acciden- 
tally let  loose  upon  a  civilized  community,  is  to  be  hunted  down 
at  all  hazards.  The  presence  of  a  foreign  body  in  the  canal  is, 
after  all,  however,  not  a  very  serious  matter.  Children  do  not 
usually  push  them  in  far  enough  to  do  any  harm.  It  is  the 
meddlesome  interference  of  nurses  and  friends,  and  sometimes 
of  unwise  practitioners,  that  forces  them  into  dangerous  posi- 
tions. There  was  a  notion  prevalent  in  England,  in  Shakspeare's 
times,1  that  poison  poured  into  the  ears  was  as  dangerous  as  if 

1  Hamlet,  Act  III.,  Scene  2. 


INANIMATE   FOREIGN   BODIES.  185 

taken  into  the  stomach ;  and  from  this,  in  some  manner  or  other, 
has  come  the  idea  that  a  foreign  body  in  the  ear  becomes  at  once 
a  very  dangerous  thing. 

It  would  be  well,  if  this  fear  of  foreign  bodies  in  the  ear, 
were  transferred  to  cases  where  they  have  entered  the  eyeball, 
where  the  most  serious  results  do  occur  from  the  neglect  to 
promptly  remove  a  foreign  substance.  Unskilful  or  indiscreet 
attempts  to  remove  a  foreign  body  from  the  ear,  are  often  more 
dangerous  than  the  foreign  body  itself.  In  the  case  of  a  foreign 
body  in  the  eye,  it  is  the  loss  of  sight  that  is  threatened,  and  it  is 
usually  the  worst  that  can  happen  ;  but  it  is  not  a  very  rare  ex- 
perience, that  improper  attempts  to  remove  a  foreign  body  from 
the  ear,  have  cost  the  life  of  the  patient. 

When,  therefore,  a  child  is  brought  to  the  practitioner,  in 
whose  ear  there  is,  or  there  is  supposed  to  be,  a  foreign  body,  let 
him  first,  by  ocular  examination,  be  sure  that  the  diagnosis  is 
correct,  and  then  let  him  attempt  to  remove  it  by  a  safe  means. 

"First  catch  your  hare,"  is  the  quaint  and  familiar  beginning 
of  the  old  receipt  for  cooking  this  animal ;  and  in  imitation  of 
this  sage  advice,  the  writer,  taught  by  experience  that  the  diag- 
nosis of  mothers  and  nurses  is  not  always  to  be  trusted,  would 
urge  upon  his  readers  the  wisdom  of  not  attempting  to  remove 
a  foreign  body  which  he  cannot  see.  There  is  nothing  more 
deceptive  than  the  tactile  examination.  Again  and  again,  have 
I  seen  physicians  click  with  a  probe,  what  they  supposed  to  be 
a  foreign  body,  when  they  were  simply  striking  the  bony  wall 
of  the  canal.  The  surgeon  should  not  take  the  testimony  of 
the  most  intelligent  nurse  in  the  world,  as  to  the  presence  of  a 
foreign  body  in  the  ear,  unless  he  sees  it  himself.  Such  testi- 
mony is  only  valuable  to  prove  that  a  foreign  body  was  once  in 
the  ear.  Any  attempt  to  remove  a  foreign  body  that  is  not  seen, 
but  which  is  supposed  to  be  in  the  ear,  will  usually  lead  to  a  dan- 
gerous and  mortifying  failure.  Even  when  it  is  seen,  a  forcible 
or  violent  attempt  is  always  a  dangerous  procedure. 

Voltolini,1  in  writing  on  this  subject,  says,  "that  even  the 
point  of  a  dagger,  if  allowed  to  quietly  remain  in  the  ear,  will 
not  do  as  much  harm  as  forcible  attempts  to  remove  it." 

The  danger  to  be  apprehended  from  attempts  to  remove  a 
foreign  body  by  the  use  of  force  is,  that  it  will  be  pushed  down- 
ward in  the  ear,  and  through  the  membrana  tympani  into  the 
cavity  of  the  tympanum,  and  even  into  the  labyrinth.  Unfor-  - 
tunately  for  the  fair  fame  of  surgical  science,  such  cases  are  on 
record. 

1  Monatsschrif t  f iir  Olirenheilkunde,  Jalirgang  II. ,  Xo.  xi. 


186  INANIMATE   FOKEIGN   BODIES. 

Treatment. — If  the  physician  see  a  case  in  which  a  foreign 
body  has  really  got  into  the  auditory  canal — a  fact  which  he 
should  determine  by  the  use  of  the  speculum  and  the  otoscope — 
before  it  has  been  meddled  with,  he  will  almost  always  be  able 
to  remove  it  by  the  process  of  syringing  the  ear  with  warm 
water.  Children,  however  young,  will  readily  submit  to  this 
operation,  and  it  is  almost  always  successful,  if,  as  I  have  said, 
there  have  been  no  previous  manipulations  with  instruments. 
Unfortunately,  however,  the  cases  are  not  usually  seen  by  a 
physician  until  the  friends  of  the  little  patient,  having  found  by 
the  child's  own  statement  that  a  bead,  or  a  pea,  or  a  shoe-button, 
or  the  like,  is  in  the  canal,  and  having  been  able  to  see  it,  have 
pushed  it  well  in,  in  their  misguided  zeal  to  remove  that  which 
in  itself  is  not  dangerous  to  the  ear  or  its  functions. 

Many  cases  are  on  record  where  foreign  bodies,  which  had 
not  occluded  the  auditory  passage,  have  remained  in  it  for  years 
without  doing  harm.  Thus  Wreden1  reports  a  case  in  which  he 
removed  a  button  from  the  outer  ear,  which  had  remained  at  the 
junction  of  the  osseous  and  cartilaginous  canal  of  a  boy  of  seven- 
teen, for  twelve  years,  and  without  doing  any  harm.  If,  how- 
ever, the  foreign  body  has  become  impacted  by  the  attempts  to 
remove  it,  and  if  serious  inflammatory  symptoms  have  arisen,  it 
is  better  to  wait  until  the  latter  have  subsided  before  any  further 
attempts  at  removal  are  made. 

Then,  if  instruments  are  to  be  used,  the  child  should  be  placed 
under  the  influence  of  ether,  and  by  means  of  a  small  bent  probe 
or  hook  (a  wire  loop  will  often  do  good  service),  or  the  instrument 
used  for  dividing  the  capsule  of  the  lens  in  the  operation  of  ex- 
traction, it  should,  if  possible,  be  dislodged  from  its  wedged 
position,  and  then  removed  by  the  syringe.  No  manipulation  of 
this  kind  should  be  attempted,  however,  unless  the  foreign  body 
is  well  illuminated,  so  that  the  surgeon  can  see  exactly  what  he 
is  doing  during  the  whole  of  his  manipulations. 

In  cases  where  injections  made  while  the  patient  is  in  an  up- 
right position,  do  not  remove  the  foreign  body,  Voltolini  has 
adopted  the  following  method  with  success  : 

The  child  is  laid  upon  a  table,  so  that  its  head  may  hang  a 
little  over  the  end  of  it.  The  membrana  tympani  then  forms  a 
plane  with  the  upper  wall  of  the  auditory  canal,  that  runs  ob- 
liquely downward.  The  syringing  is  then  performed  as  usual. 
In  two  cases  Voltolini  has  succeeded  in  removing  the  foreign 
body  by  this  manoeuvre,  when  the  ordinary  method  did  not 
succeed. 

1  Monatssclirift  fiir  Ohrenlieilkunde,  Jahrgang  III.,  No.  12. 


INANIMATE  FOEEIGN   BODIES.  187 

Voltolini  has  also  used  the  galvano-caustic  in  breaking  up 
the  so-called  Johannis  brod,  or  carob  bean.  The  bean  having 
become  so  firmly  wedged  into  the  ear  that  it  was  impossible  to 
move  it  one  way  or  the  other,  he  inserted  the  needle  "with 
lightning-like  rapidity "  into  the  body,  and  when  it  cooled,  the 
bean  broke  with  a  snap  audible  to  the  patient  and  to  those  about. 
When  sufficiently  broken  up,  it  was  removed  by  syringing. 

Foreign  bodies,  such  as  peas,  beans,  and  the  like,  are  harder 
to  remove  after  they  have  been  in  the  ear  for  some  time,  than 
metallic  bodies,  because  they  swell  and  thus  become  wedged 
firmly  in  the  canal,  and  if  they  have  been  pushed  into  the  cavity 
of  the  tympanum  they  excite  still  more  trouble  and  become  still 
more  unmanageable. 

I  have  notes  of  forty -four  cases  of  foreign  bodies  in  the  ear 
that  have  occurred  in  my  practice,  and  I  have  never  but  in  one 
case  failed  to  remove  the  offender,  and  then  I  saw  the  patient 
but  once  for  a  few  moments.  The  syringing  did  not  succeed, 
and  I  asked  the  mother  to  bring  the  patient  to  my  clinic  at  the 
hospital,  where  she  might  be  placed  under  the  influence  of  an 
ansesthetic,  but  she  was  not  brought. 

In  one  case,  when  the  child  first  came  under  my  observation, 
a  button  was  lodged  in  the  cavity  of  the  tympanum  by  efforts 
to  remove  it.  I  syringed  it  in  vain  on  several  occasions.  I  then 
proceeded  carefully  with  instruments,  the  patient  being  anaes- 
thetized. This  attempt  also  failed.  I  then  ordered  the  mother 
to  syringe  the  ear  three  times  a  day,  which  was  necessary  on 
account  of  the  purulent  otitis  media  which  had  been  set  up  by 
the  presence  of  the  button  in  the  cavity  of  the  tympanum,  and 
I  also  advised  the  careful  use  of  poultices.  To  my  delight,  in 
about  four  weeks  I  had  the  satisfaction  of  removing  the  button 
from  the  canal,  where  it  had  been  brought  by  the  syringing  and 
the  use  of  the  poultices. 

For  years,  I  had  under  my  care,  a  little  child  of  four  years 
of  age,  who,  according  to  her  own  statement  to  her  nurse,  put 
an  ordinary  shoe-button,  made  of  papier-mache,  in  her  ear.  As 
soon  as  the  nurse's  attention  was  called  to  the  case,  she  re- 
ported it  to  the  family,  who  sent  for  a  physician,  who  saw  the 
button,  and  attempted  to  remove  it,  under  chloroform,  using  for 
this  purpose  a  small  elevator.  It  is  stated  that  half  the  button 
was  removed  in  this  way ;  but  the  other  half  could  not  be  dis- 
lodged. 

In  a  few  days,  the  child  having  become  very  weak  from  the 
operation  and  the  anaesthetic,  I  was  called  in  consultation.  A 
careful  examination  was  made.  The  membrana  tympani  was 
found  to  be  gone,  there  was  considerable  swelling  of  the  canal, 


188  FOREIGN    BODIES. 

but  the  button  was  not  to  be  seen  either  by  the  physician  or 
myself,  although  he  thought  he  detected  it  with  the  probe. 

Another  surgeon  was  called  in,  and  he  was  not  able  to  find  a 
foreign  body,  and  the  child  was  under  treatment  for  years  for 
a  chronic  suppuration  of  the  middle  ear,  the  membrana  tympani 
and  the  ossicula  being  gone,  and  the  hearing  irretrievably  in- 
jured. 

I  recite  such  cases,  in  order  to  show  what  harmful  conse- 
quences may  result,  from  the  most  conscientious  attempts  to 
remove  a  foreign  body  with  instruments. 

No  engravings  are  given  in  this  volume  of  the  numerous 
hooks,  forceps,  perforators,  drills,  picks,  et  id  genus  omne,  that 
have  been  devised  by  surgeons,  with  more  ingenuity  than  wis- 
dom, for  the  removal  of  foreign  bodies  from  the  ear,  because  I 
firmly  believe  that  the  vast  majority  of  such  instruments  are 
very  dangerous  weapons ;  while  they  are  usually  greatly  in- 
ferior in  efficiency  to  the  use  of  the  warm  water  and  syringe. 
Cases  will  occur,  however,  in  which  syringing  will  not  be  suf- 
ficient;  but  I  should  not  hasten  unduly,  unless  the  body  had 
become  impacted  in  the  tympanic  cavity,  or  was  causing  un- 
pleasant or  serious  symptoms.  In  such  cases  the  ordinary  arma- 
mentarium of  the  surgeon  will  generally  contain  instruments 
adapted  for  the  individual  cases  as  they  occur.  Let  him  remem- 
ber, however,  that  once  beyond  the  membrana  tympani,  he  is 
dealing  with  parts  whose  injury  becomes  dangerous  not  only  to 
hearing  but  to  life. 

Dr.  Elsberg '  thinks  very  highly  of  a  delicate  double  screw 
hook,  with  two  little  prongs  pointing  in  different  directions.  It 
can  be  introduced  into  the  canal  and  laid  against  a  sensitive 
part,  according  to  Elsberg,  without  causing  pain  or  injury.  By 
twirling  it  around  from  left  to  right,  the  prongs  will  endeavor 
to  bury  themselves  into  the  substance  they  rest  against ;  on  re- 
versing the  motion  it  unscrews,  taking  no  hold,  or  letting  go  if 
previously  fastened.  Dr.  Elsberg,  also  uses  this  instrument  for 
foreign  bodies  in  the  nose.  He  only  advises  its  use  in  the  ear  in 
exceptional  cases,  that  is,  those  in  which  syringing  fails.  For 
the  removal  of  impacted  cotton,  such  as  one  case  reported  by 
Elsberg,2  I  have  no  difficulty  when  I  use  the  ordinary  angular 
forceps,  with  delicate  teeth.  I  have  never  been  in  the  habit  of 
classifying  all  the  cases  where  wads  of  cotton  are  pushed  down 
to  the  bottom  of  the  canal,  in  cases  of  aural  disease,  among  for- 
eign bodies.  They  are  very  common  accidents  in  the  treatment 

1  Medical  Record.  February  1,  1870. 

2  Detroit  Lancet,  September,  1882. 


INSTRUMENTS    FOR    FOREIGN    BODIES.  189 

of  aural  disease  by  the  patient  himself,  and  hardly  seem  to  me 
worthy  of  more  than  an  allusion. 

Patients  who  use  Toynbee's  artificial  drum-head,  occasionally 
lose  the  disk  of  rubber  in  the  ear,  and  come  to  a  surgeon  for  its 
removal.  This  is  usually  easily  accomplished  by  the  syringe. 
If  not,  a  bent  probe  may  be  used  to  lift  up  the  disk  to  a  situation 
where  it  can  be  readily  grasped  with  the  forceps.  Such  patients 
from  their  experience  in  this  direction,  are  very  tractable  and 
tolerant  of  manipulations  in  the  canal.  Consequently  the  re- 
moval of  foreign  bodies  from  their  ears  is  a  very  simple  matter, 
as  a  rule,  certainly  as  compared  with  a  similar  operation  upon 
children.  Some  years  after  Dr.  Elsberg  had  published  his  ac- 
count of  his  instrument,  he  found  that  other  surgeons,  some 
forty  years  before  him,  had  invented  similar  instruments.  It 
will  be  found  on  study  of  the  old  text-books,  especially  those  of 
Lincke  and  Frank,  that  most,  if  not  all,  of  the  modern  inventors 
of  instruments  for  extracting  foreign  bodies  from  the  ear,  have 
been  anticipated,  and  that  there  remains  not  much  to  discover 
in  this  field. 

For  example,  Dr.  Kinne l  recommends  a  hook  made  of  a  pin. 
Dr.  Gross'  instrument  is  essentially  this  instrument,  as  is  the 
cystotome  used  in  cataract  operations  and  often  used  by  aural 
surgeons.  It  is  passed  behind  or  to  the  side  of  the  foreign  body, 
when  it  is  easily  fastened  upon,  and  a  dislodgement  occurs. 
One  of  my  staff  at  the  Manhattan  Eye  and  Ear  Hospital,  Dr.  F. 
M.  Wilson,  lately  removed  .a  bead  from  the  auditory  canal  of  a 
child  by  "stringing"  it  upon  a  Bowman's  lachrymal  probe.  Dr. 
Wilson  intended  to  use  the  probe  to  dislodge  the  bead,  but  find- 
ing he  could  easily  pass  it  into  the  eye  of  the  bead,  he  did  so. 
Dr.  Knapp "  lays  some  stress  upon  the  use,  in  difficult  cases,  of  a 
flexible  silver  hook,  the  concave  side  of  which  is  roughened  and 
hollowed  out.  Such  a  hook,  it  is  claimed,  is  less  likely  to  slip  off 
the  foreign  body.  Dr.  Knapp  adds  his  testimony  to  the  nearly 
unanimous  general  statement  of  experienced  surgeons  upon  this 
subject,  that  he  does  not  remember  a  single  case  in  which  he 
failed  to  remove  a  foreign  body  by  syringing  or  by  the  hook. 
The  recommendation  by  Politzer 3  to  use  alcohol  in  the  ear  to 
avoid  swelling  of  the  canal  from  the  prolonged  use  of  water,  is 
a  good  one,  and,  as  Knapp  says,  it  may  be  enlarged  so  as  to  in- 
clude its  use  for  swelling  of  the  canal  from  the  swelling  of  the 
foreign  body  itself,  since  alcohol  is  such  an  excellent  remedy  for 
the  shrinkage  of  proliferating  tissue. 

1  Detroit  Lancet,  June,  1882.  "  Medical  Record,  January,  1883,  p.  25. 

3  Text-book,  translation,  p.  628. 


190  DETACHMENT    OF    THE    AURICLE. 

The  ancient  suggestion  of  Hippocrates,  Paul  of  ^Egina,  'and 
Du  Verney,  which  was  revived  and  re-suggested  by  Troltsch  in 
1802,  to  detach  the  auricle  from  the  ear,  will  be  found  worthy  of 
consideration,  when  it  is  found  impossible  to  remove  a  foreign 
body  through  the  canal.  It  is  not  a  dangerous  operation,  and  it 
is  much  to  be  preferred  to  any  risk  of  serious  injury  to  the  cavity 
of  the  tympanum  or  the  labyrinth. 

Following  the  suggestion  of  Troltsch,  I  performed  the  opera- 
tion of  detachment  of  the  auricle  for  the  removal  of  a  foreign 
body  in  April,  1874.  In  1881  Dr.  J.  Orne  Green '  performed  the 
same  operation,  and,  in  1882,  Dr.  A.  H.  Buck.2 

According  to  Politzer,3  it  has  also  been  performed  by  Lan- 
genbeck  (Berliner  Med.  Wochenschrift,  1870),  who  removed  a 
button  from  the  tympanic  cavity  after  partial  separation  of  the 
posterior  attachment  of  the  auricle.  Moldenhauer,4  in  1881,  also 
removed  a  stone  from  the  auditory  canal  of  a  boy  of  three  and  a 
half  years  of  age,  after  completely  detaching  the  auricle  posteri- 
orly. Schwartze  adds  a  note  to  Moldenhauers  article,  the  latter 
writer  having  quoted  him  from  Troltsch's  text-book,  to  state 
that  he  has  separated  the  auricle  in  three  cases  for  the  removal 
of  foreign  bodies  from  the  ear.  Schwartze  gives  no  more  exact 
date  to  his  operations  than  to  say,  "  In  the  beginning  of  the  last 
ten  years,"  (Aus  dem  Anfange  des  vorigen  Decenniums).  This 
probably  means  in  the  years  1872,  1873,  or  1874.  From  all  this 
it  appears,  that  either  Schwartze  or  myself,  was  the  first  to  per- 
form this  operation,  after  it  was  suggested  by  Paul  von  JEgina 
(see  introductory  chapter),  and  re-suggested  by  Troltsch  in  the 
first  edition  of  his  text-book. 

Schwartze 5  urgently  advises  against  the  cutting  out  of  pieces 
of  the  cartilaginous  canal  or  a  partial  chiselling  out  of  the  pos- 
terior wall  of  the  osseous  canal,  in  order  to  get  a  larger  field  of 
operation  in  removing  a  foreign  body  from  the  ear. 

The  case  in  which  I  performed  this  operation,  was  that  of  a 
gentleman,  who  when  about  sixteen  years  of  age,  was  accident- 
ally shot  by  himself,  the  shot  entering  the  ramus  of  the  upper  jaw. 
The  zygoma  and  the  outer  wall  of  the  orbit  were  fractured.  The 
auricle  was  detached  and  the  lower  jaw  was  broken.  Twenty-two 
shot  were  removed  from  various  parts  of  the  face.  The  auditory 
canal  became  nearly  closed,  but  there  was  a  constant  discharge 
of  pus  from  it.  It  was  evident  that  the  bony  canal  or  tympanic 

1  Transactions  American  Otological  Society,  Vol.  II.,  p.  471. 

s  New  York  Medical  Record,  December,  1882,  p.  676. 

'Text-book,  translation,  p.  631. 

*  Archiv  fur  Ohrenheilkunde,  Bd.  XVHI. ,  p.  59.  B  Loc.  cit. 


DETACHMENT    OF    THE    AURICLE.  191 

cavity,  or  both  were  fractured,  for  pieces  of  dead  bone  came 
away.  Granulations  sprouted  up  in  the  canal,  and  severe  head- 
aches constantly  recurred,  so  that  the  patient  was  prevented 
from  engaging  in  business  or  study.  Lead  probes  were  used  to 
keep  the  canal  dilated.  In  1874  one  was  lost  in  the  canal  or 
tympanic  cavity,  and  all  attempts  to  remove  it  had  failed. 
Then  Mr.  W-  -  came  under  my  care.  I  used  the  usual  means 
to  find  and  remove  the  style— ISTelaton's  probe,  sponge  tents,  and 
so  forth — but  I  was  unsuccessful.  I  was  never  certain  that  I  had 
found  it.  The  canal  was  narrow  and  inflamed,  the  drum-head 
was  gone,  and  manipulation  was  difficult.  I  then  determined 
to  detach  the  auricle.  The  patient  was  placed  under  ether,  and 
with  the  assistance  of  Dr.  F.  H.  Rankin,  now  of  Newport,  R.  I., 
and  Dr.  Sturgis,  of  this  city,  I  separated  the  auricle  from  the 
bone  posteriorly,  and  searched  for  the  style.  Similarly  with 
the  experience  of  Buck  and  Moldenhauer,  I  did  not  find  that  the 
operation  enlarged  the  field  of  operation  or  exposed  the  tympanic 
cavity,  as  freely  as  I  had  been  led  to  hope.  Yet  the  detachment 
was  of  very  great  and  essential  assistance.  The  style  ivas  not 
found,  but  a  shot  was  removed  from  the  tympanic  cavity.  The 
wound  was  united  by  suture  and  healed  by  first  intention,  the 
facial  neuralgia  passed  away  after  the  removal  of  the  shot,  and 
in  1879  the  leaden  style  came  away  spontaneously,  the  patient 
all  the  time  taking  good  care  of  the  purulent  affection  of  the 
middle  ear  and  canal  by  syringing,  and  so  forth.  The  shot 
must  have  made  the  pressure  that  caused  the  neuralgia,  since  it 
ceased  when  this  was  removed. 

The  operation  of  detachment  of  the  auricle,  has  certainly  now 
a  sufficient  foothold  in  the  experience  of  surgeons,  to  relieve  it 
from  the  stigma  cast  upon  it  by  a  distinguished  professor,  who 
once  said  that  "the  idea  of  separating  the  auditory  canal  from 
the  squamous  process  of  the  temporal  bone,  with  a  view  of  ob- 
taining access  to  the  extraneous  substance,  as  suggested  by  Von 
Troltsch,  is  so  absurd  that  it  ought  to  be  ranked  among  the  ex- 
ploded notions  of  the  barbarous  ages."  Another  writer,  in  the 
American  Journal  of  Otology,  January,  1881,  alluded  to  the 
operation  only  to  speak  of  its  "  utter  futility,"  but  in  spite  of  this, 
it  is  now  a  sound  surgical  procedure,  based  on  an  experience  that 
fully  justifies  its  performance,  whenever  it  may  be  indicated  by 
an  inability  to  get  at  a  foreign  body  through  the  canal. 

Dr.  Orne  Green  performed  the  operation  on  May  11,  1881,  upon  a  man  who, 
•with  suicidal  intent,  placed  the  muzzle  of  a  small  revolver  directly  in  the  right  au- 
ditory meatus,  and  fired  two  shots  in  that  passage.  Three  days  after,  the  patient 
was  brought  to  the  City  Hospital  of  Boston,  complaining  only  of  headache,  sore- 


192  DETACHMENT    OF    THE    AURICLE. 

ness  of  the  ear  and  face  on  the  side  of  the  injured  ear.  The  meatus  was  found 
filled  with  half-burnt  powder,  and  with  a  probe  loose  foreign  bodies  were  detected. 
Three  days  after  admission  a  semi-circular  incision  was  made  above  and  behind 
the  auricle,  through  the  periosteum,  and  the  periosteum  with  the  auricle  and 
cartilaginous  rneatus  earned  forward  until  the  edge  of  the  osseous  meatus  was 
reached.  Dr.  Green  then  readily  seized  a  loose  foreign  body,  an  irregular  bit  of 
lead.  After  syringing  and  digging  out  masses  of  powder,  the  anterior  osseous  wall 
of  the  meatus  was  found  to  be  loose  and  was  removed.  A  porcelain-tipped  probe 
detected  a  second  mass  of  lead  firmly  wedged  in.  This  was  loosened  and  removed. 
A  third  mass  of  lead,  also  detected  by  the  probe,  was  gradually  loosened  and  re- 
moved. The  auricle  was  replaced,  the  incision  united  by  sutures,  and  a  carbolic 
dressing  applied.  The  patient  did  well  for  four  days,  he  then  refused  to  eat, 
became  delirious,  and  died  six  days  after  the  operation.  The  post-mortem  ex- 
amination showed  serum  beneath  the  pia  mater  and  congestion.  The  dura  mater, 
pia  mater,  and  brain-substance  just  over  the  roof  of  the  tympanum  were  firmly 
adherent  and  could  not  be  separated  from  the  bone.  Just  above,  passing  into  the 
brain  for  half  an  inch,  was  a  small  sinus,  evidently  the  track  of  a  piece  of  one 
bullet.  There  were  small  bits  of  bone  embedded  in  the  dura  mater  at  this  point. 
On  examination  of  the  right  temporal  bone  the  whole  anterior  wall  of  the  osseous 
meatus  was  found  to  be  wanting,  the  tissues  in  front  of  the  ear  around  the  glen- 
oid  fossa  were  gangrenous.  The  roof  of  the  tympanum  was  perforated  by  an 
opening  8  mm.  long  and  4  mm.  broad.  The  bone  within  the  tympanic  cavity  was 
entirely  bare.  The  ossicles  were  gone,  and  the  lower  edge  of  the  fenestra  ovalis 
was  broken  away.  No  lead  was  found  in  the  bone.  The  lead  removed  weighed 
in  all  48J  grains.  Two  bullets  of  the  size  used  would  weigh  60  grains,  leaving 
llf  grains,  which  in  all  probability  entered  the  brain.  When  Dr.  Green  first  ex- 
amined this  case,  he  found  that  the  meatus  was  unusually  small,  and  this  fact, 
with  the  certainty  that  if  the  bullets  were  found  they  would  be  flattened,  caused 
him  to  undertake  the  operation  of  detaching  the  auricle. 

Dr.  Green  goes  on  to  state,  that  if  one  portion  of  the  bullet 
had  not  glanced  upward,  and  passed  through  the  roof  of  the 
tympanum  into  the  brain,  a  condition  impossible  to  diagnosticate 
beforehand,  there  were  no  reasons  why  recovery  should  not  have 
occurred.  Langenbeck,  by  the  aid  of  this  operation,  removed  a 
small  button  which  had  entered  the  left  tympanic  cavity,  and 
caused  a  very  extensive  reflex-neurotic  pain  in  the  arms,  upper 
jaw,  with  hyperalgesia  of  the  skin  of  the  affected  parts,  and 
finally  contraction  of  the  left  hand.  The  wound  healed  by  first 
intention,  except  a  slight  fistula  under  the  parotid.  The  patient 
recovered  in  three  days  from  the  reflex  symptoms. ' 

Dr.  Buck's  case  should  also  be  given,  for  I  am  sure  a  careful 
consideration  of  this  subject,  will  establish  this  operation  in  full 
favor,  especially  in  cases  where  the  foreign  body  has  entered 
the  tympanic  cavity,  and  where  in  addition  to  this  the  meatus 
externus  and  canal  are  abnormally  small.  It  goes  without  say- 

1  Troltsch,  Lehrbuch,  Sechste  Auflage,  p.  510.  Leipzig,  1877.  Berlin.  Klin.  Wochen- 
schrift,  1876,  No.  15. 


DETACHMENT    OF    THE    AURICLE.  193 

ing,  as  Troltsch  said  when  he  advised  a  revival  of  the  operation, 
that  it  is  to  be  reserved  for  urgent  cases.  Yet  no  surgeon  need 
be  deterred  from  it,  by  the  idea  that  it  is  a  formidable  surgical 
procedure.  It  is  far  from  this,  and  I  have  no  reason  for  with- 
drawing my  recommendation  of  it,  which  I  gave  in  the  first 
edition  of  this  book,  published  in  1873. 

The  case  in  which  Dr.  Buck  detached  the  auricle,  is  in  brief 
as  follows  : 

The  patient  was  a  boy  of  nine  years,  in  whose  right  auditory  canal  a  playmate 
had  thrown  or  pushed  a  bean.  An  effort  was  made  to  remove  it  by  a  physician, 
but  it  failed.  The  boy  was  then  brought  to  Dr.  Francis  Delafield,  of  New  York, 
who,  with  Dr.  Buck — the  little  patient  being  under  the  influence  of  sulphuric 
ether — tried  to  dislodge  the  bean,  which  was  seen  between  the  anterior  and  pos- 
terior walls  of  the  canal  near  the  membrana  tympani.  These  attempts  were 
made  with  steel  hooks.  The  bean  was  what  is  known  as  a  locust  bean,  very  hard, 
"the  surface  is  essentially  as  hard  as  ivory"  (Buck).  A  locust  bean  measures 
10  mm.  in  length,  7  mm.  in  breadth,  and  5  mm.  in  thickness.  After  waiting  for 
some  days  and  making  experiments  with  a  dental  drill,  and  by  soaking  the  beans 
in  hot  water  and  nitric  acid,  and  finding  the  results  unsatisfactory,  Dr.  Buak 
determined  to  detach  the  auricle,  which  he  did.  The  bleeding  was  profuse. 
The  bean  was  seen  lying  transversely  across  the  long  axis  of  the  canal,  but  it  was 
so  firmly  impacted  that  there  was  great  difficulty  in  removing  it  with  the  steel 
hook,  although  this  was  finally  accomplished.  The  case  finally  did  well,  although 
the  auricle  healed  slowly,  and  granulations  formed  in  the  auditory  canal.  A  per- 
foration of  the  membrana  tympani  was  found  after  the  operation.  This  Dr.  Buck 
is  inclined  to  think  was  caused  by  the  attempts  at  removal.  A  note  from  the 
physician  who  first  saw  the  case  just  narrated,  to  Dr.  Buck,1  states  that  he  never 
saw  the  foreign  body  at  all,  but  that  attempts  were  made  to  remove  it  by  "a 
nurse  or  one  of  the  lady  guests  at  the  house,"  who  used  a  hair-pin,  and  then  by 
"  a  gentleman  guest,"  who  used  a  crochet-needle. 

Thus  the  old  story  is  repeated.  Nowhere  do  "fools  step  in 
where  angels  fear  to  tread,"  more  promptly,  than  when  a  foreign 
body  has  entered  the  auditory  canal  of  some  luckless  child.  This 
locust  bean  was  probably  firmly  lodged  by  the  hair-pin  and 
crochet-needle  of  the  "lady  and  gentleman  guests"  who  took 
part  in  the  hunt  after  a  bean,  which  would  have  been  easily  re- 
moved by  the  syringe,  if  it  had  been  left  where  it  first  lodged. 
This  case  caused  Dr.  Buck,  who  formerly  looked  somewhat 
askance  at  the  syringe  as  the  first  means  to  be  tried  for  remov- 
ing a  foreign  body  from  the  ear,  to  state  that  "  it  is  a  fair  infer- 
ence to  draw  from  this  case,  that  it  is  decidedly  better  for  the 
general  practitioner,  when  called  upon  to  remove  a  foreign  body 
from  the  ear,  to  restrict  his  efforts  to  the  employment  of  the 
syringe  with  tepid  water." 

1  Medical  Record,  January,  1883. 
13 


194  FOREIGN    BODIES. 

Dr.  Lowenberg1  reports  an  ingenious  method  by  which  he 
removed  a  small  ivory  ball,  from  the  tip  of  a  quill  pen-holder, 
which  had  been  forced  into  the  ear  of  a  boy  nine  years  of  age. 
Various  attempts  at  removal,  by  other  hands,  wounded  the 
canal,  perforated  the  membrana  tympani,  and  excited  severe  in- 
flammation. After  the  inflammation  had  subsided.  Dr.  Lowen- 
berg attempted  to  remove  the  body  by  syringing,  by  Valsalva's 
and  Politzer's  methods  of  inflating  the  ears  ;  but  he  failed.  He 
then  extracted  the  ball  by  bringing  the  point  of  a  small  brush, 
dipped  in  joiners'  glue,  in  contact  with  its  outer  surface,  allow- 
ing the  glue  to  harden,  and  then  extracting  brush  and  ball  to- 
gether. 

Dr.  E.  H.  Clarke,  who  is  quoted  by  Blake  in  the  same  report 
from  which  I  have  taken  the  description  of  Dr.  Lovreiiberg's 
method,  once  adopted  a  similar  procedure  with  success.  The 
foreign  body  was  a  hard,  smooth  ball,  and  it  was  extracted  by 
passing  a  thread  through  a  small  square  of  adhesive  plaster, 
and  bringing  the  latter,  by  means  of  a  fine  tube,  into  contact 
with  the  surface  of  the  ball,  when  sunlight  was  concentrated 
upon  it  by  means  of  a  lens,  until  it  softened  and  adhered,  when 
it  was  easily  extracted.  These  two  methods  are  certainly  to  be 
commended  as  both  ingenious  and  safe. 

Of  the  cases  of  foreign  body  in  the  ear,  that  I  have  seen  in 
private  practice,  very  few  are  worthy  of  more  especial  notice 
than  I  have  already  given  them. 

In  two  of  the  cases,  both  male  adults,  the  foreign  bodies  were 
thrown  in  the  ear.  In  one  case  the  patient  was  passing  along 
the  street  when  a  bean  was  thrown  into  his  ear.  The  bean  was 
dislodged  by  means  of  a  small  hook,  and  then  removed  with  an 
angular  forceps.  In  the  other  case  some  young  men  were  en- 
gaged in  "  flipping"  beans,  and  one  entered  the  auditory  canal. 
It  was  displaced  by  a  probe,  and  then  removed  by  a  syringe.  In 
another  case,  an  okra  seed  had  been  pushed  through  the  mem- 
brana tympani  in  the  efforts  to  remove  it.  Suppuration  of  the 
middle  ear  existed  when  I  saw  the  child,  and  the  okra  seed 
could  not  be  seen.  In  the  course  of  a  year  it  came  out  during 
the  syringing,  which  was  advised  as  a  means  of  treating  the 
ulceration.  There  was  one  case,  in  which  a  cockroach  entered 
the  ear  of  a  man  of  thirty-six.  He  came  to  the  office,  stating 
that  he  had  pain  in  the  ear  during  the  night,  but  without  know- 
ing the  cause.  The  insect  was  easily  removed  by  the  syringe. 
In  another  case,  that  of  a  lady,  quite  a  large  quantity  of  sand 

1  Report  on  the  Progress  of  Otology,  by  C.  J.  Blake,  Transactions  American  Oto- 
logical  Society,  1872. 


MARION    SIMS    ON    FOREIGN    BODIES.  195 

was  removed  from  the  canal  and  from  the  surface  of  the  drum- 
head. Of  the  Manhattan  Hospital  cases,  a  very  large  proportion 
were  removed  without  an  anaesthetic,  and  whether  with  another 
instrument  than  the  syringe  or  not,  at  least  without  difficulty. 
Ten  were  removed  under  the  use  of  sulphuric  ether,  and  chloro- 
form was  used  in  one  case.  Failure  to  remove  the  foreign  body 
did  not  occur  in  any  case.  Two  of  the  cases  are  said  to  have 
been  injured  by  instruments  before  they  came  to  the  hospital. 
If  the  notes  had  been  fully  kept,  a  greater  number  of  cases  of  in- 
jury from  attempts  at  removal  would,  I  think,  have  been  shown. 

In  one  of  the  cases  the  foreign  body  had  been  pushed  into 
the  tympanic  cavity.  It  was  removed,  five  days  after  the  first 
visit  to  the  hospital,  by  Dr.  Parclee,  he  having  dislodged  it  at  the 
first  visit. 

There  were  two  cases  in  which  no  foreign  body  was  in  the 
ear,  although  one  was  supposed  to  be.  In  one  case,  a  piece  of 
the  point  of  a  lead-pencil  broke  off  in  the  ear  while  the  patient 
was  carrying  it  in  her  hand.  She  ran  against  some  obstruction 
and  broke  the  pencil  in  her  ear.  It  was  easily  removed  with  the 
syringe. 

My  distinguished  countryman,  the  late  Dr.  J.  Marion  Sims, 
published  an  article,  illustrated  by  three  cases,  in  the  American 
Journal  for  Medical  Sciences,1  that  ver}r  warmly  and  ably  advo- 
cated the  use  of  the  syringe  for  the  removal  of  foreign  bodies 
from  the  ear,  but  which  did  not  receive  the  attention  it  deserved. 

This  was  -the  first  important  article  Dr.  Sims  ever  published. 
So  impressed  was  the  literature  of  the  period  of  Dr.  Sims'  writ- 
ing, with  the  idea  that  forceps,  and  so  forth,  must  first  be  used 
before  any  other  means  are  tried,  that  it  was  only  by  accident 
as  it  were,  when  washing  away  the  blood  caused  by  fruitless 
attempts  to  remove  a  foreign  body  by  such  instruments,  that  he 
found  the  syringe  and  warm  water  the  very  best  means  of  re- 
moving such  offenders.  Dr.  Sims  gives  Mr.  Carpenter,  of  Castle 
Comer,  Ireland,  the  credit  for  being  the  first  to  call  the  attention 
of  the  profession  to  the  universal  applicability  of  the  syringe  for 
the  removal  of  foreign  trodies  from  the  ear.  He  also  narrates 
the  experience  of  no  less  a  person  than  Sir  Benjamin  Brodie, 
who'with  characteristic  British  honesty,  tells  us  how  lie  failed  to 
get  a  foreign  body,  a  pea,  from  the  ear,  •after  using  all  sorts  of 
methods,  and  finally  left  it  to  rot  and  come  out  of  itself,  or  "  to 
be  washed  out  by  a  syringe." 

Dr.  Sims  maintained  his  interest  in  this  subject  long  after  he 
had  won  great  fame  as  a  gynaecologist.  He  read  a  paper  upon 


'Vol.  ix.,  1845,  p.  336. 


196  FOREIGN    BODIES — CASES. 

" The  Extraction  of  Foreign  Bodies  from  the  Ear"  before  the 
British  Medical  Association  in  1878,'  in  which  he  repeated  his 
views  as  to  the  value  of  the  syringe.  He  criticised  the  ear  syr- 
inges made  in  London  as  being  clumsy,  as  having  a  large 
nozzle,  so  that  they  throw  a  large  stream  of  water.  Dr.  Sims 
recommends  for  occasional  use,  in  removing  foreign  bodies  for 
example,  the  ear  syringe  so  commonly  sold  in  the  United  States. 
It  is  of  hard  rubber,  and  holds  about  an  ounce.  It  is  very  light 
and  is  easily  managed  with  one  hand.  Useful  as  this  syringe 
is  for  occasional  use,  it  is  usually  so  carelessly  made,  and  is  so 
small,  that  the  practitioner  who  has  much  use  for  an  aural  syr- 
inge will  prefer  one  of  metal,  a  size  or  two  larger,  but  having 
the  same,  nozzle,  and  made  on  the  same  general  plan  as  the 
"American  hard  rubber  ear  syringe."  Even  patients  who  are 
obliged  to  use  a  syringe  for  a  long  time,  will  find  a  metal  syr- 
inge the  cheapest. 

Dr.  E.  D.  Speir,"  of  Boston,  recommends  pressure  with  the 
fingers  "upon  the  skin,  close  to  and  in  front  of  the  tragus,  car- 
ried upward  and  around  the  meatus,  upon  the  auricle,  and  back 
again  to  their  starting-point,  when  the  manoeuvre  is  repeated 
several  times, ".for  the  removal  of  a  foreign  body  found  in  the 
cartilaginous  portion  of  the  canal,  and  lying  upon  the  wall. 

The  same  movements  of  the  canal,  are  advised  to  effect  a 
change  in  position  of  a  foreign  body  lying  beyond  the  centre  of 
the  cartilaginous  canal,  or  even  one  that  has  been  pressed  partly 
into  the  osseous  portion.  Dr.  Speir  gives  several  instances  in 
which  the  position  of  foreign  bodies  in  this  canal  has  been 
changed  by  this  procedure.  It  is  especially  recommended  for 
foreign  bodies  that  have  not  been  tampered  with  by  improper 
means.  It  is  just  these,  that  may  be  easily  removed  by  a  syr- 
inge. 

A  Pea  in  the  Ear  for  Thirty  Years — Unpleasant  and  Painful  Symptoms — Final 
Removal  by  the  Patient  Himself. 

My  friend,  Professor  William  Darling,  having  told  me  of  a 
well  authenticated  case  of  a  foreign  body  remaining  in  the  ear 
for  thirty  years,  at  my  request,  he  procured  the  history  for  me. 
I  regard  it  as  of  sufficient  value  to  warrant  its  insertion  in  the 
patient's  own  words. 

When  a  boy  in  Scotland,  nine  or  ten  years  old,  I  put  a  pea  into  my  right 
ear,  under  the  impression  it  would  come  out  at  my  mouth.  I  was  immedi- 

J  British  Medical  Journal,  December,  1878,  p.  868. 
s  American  Journal  of  Otology,  Vol.  III. ,  p.  197. 


FOREIGN    BODIES — CASES.  197 

ately  seized  with  excruciating  pains,  and  the  doctor  was  sent  for.  Of  course, 
I  told  «my  father  and  mother  where  the  great  pain  was  located,  but  I  neither 
told  them  nor  the  doctor  the  cause.  I  can  remember  them  holding  me  in  bed, 
while  the  doctor  was  dropping  some  liquid  into  my  ear  to  try  and  relieve  the  pain. 
The  doctor  who  attended  me  was  the  uncle  of  Professor  William  Darling,  of 
New  York,  and  I  remember  many  expedients  were  tried  to  relieve  my  agony. 
Suppuration  ensued,  and  after  a  time  I  got  b'etter,  but  the  ear  was  a  continual 
trouble  ;  if  I  got  wet  or  cold  it  went  to  that  sore  ear.  After  coming  to  Montreal, 

I  requested  the  lata  Dr.  W.  P.  S to  try  and  remove  the  pea,  but  he  would 

not  believe  there  was  any  foreign  body  in  the  ear,  and  it  was  only  after  urgent 
solicitations  that  he  at  last  extracted  what  appeared  to  me  to  be  the  half  of  the 
outer  skin  .of  the  pea,  but  which  the  doctor  said  was  only  "hardened  wax." 
After  any  violent  exertion  I  felt  as  if  the  pea  was  displaced,  until  I  got  a  night's 
sleep. 

Before. the  opening  of  the  Atlantic,  now  the  Montreal  and  Portland  railway, 
and  before  the  road  was  ballasted,  I  rode  from  Sherbrooke  to  Montreal  (100 
miles),  with  only  an  engine  and  tender,  and  the  jolting  on  the  rough  road  so 
displaced  the  pea,  that  at  night  it  was  impossible  for  me  to  sleep.  I  knew  the 
pea  was  the  trouble,  so  with  as  long  a  pin  and  as  small  a  head  as  I  could  find,.  I 
determined  to  try  and  remove  the  pea  which'  had  now  been  in  my  ear  over  thirty 
years.  After  cautiously  introducing  the  pin  into  the  ear,  a  grating  sound  was 
felt,  and  with  some  trouble  the  pin  head  was  got  over  the  pea,  and  by  slowly 
working  the  pin  back  and  forward,  gradually  the  pea  was  brought  to  the  open- 
ing, when  unfortunately  the  pin  then  slipped  out.  At  this  point,  the  narrator 
states,  he  awoke  his  wife,  who  in  attempting  to  remove  a  "  black  thing  "  which 
she  saw  at  the  meatus,  pushed  it  back.  The  patient,  however,  soon,  by  careful 
manipulation  with  the  pin,  removed  the  pea  from  the  ear. 

The  writer  then  continues :  Half  of  the  skin  still  adheres  to  the  pea,  but 
the  division  and  germinating  points  are  as  plainly  marked  to-day  as  they  were 
upward  of  fifty  years  ago.  I  am  now  sixty-one  years  of  age.  Previous  to  getting 
the  pea  out,  I  could  never  sleep  on  my  right  side,  I  was  continually  bothered  by 
a  most  annoying  singing  when  the  pea  was  in.  The  hearing  is  unimpaired. 

Dr.  Ludwig  Mayer1  has  collected  the  cases  of  foreign  bodies 
in  the  ear  that  he  has  been  able  to  find  in  the  literature  of  the 
fifty  years  preceding  1870.  The  whole  number  is  77.  Of  these 
persons 

16  were  between  1  and  10  years  of  age. 
10     "         •"       10    "    20     " 
10      "  "       20    "     50      " 

1  was  over        50 

The  age  of  the  remainder  is  unstated. 

In  66  cases  the  foreign  body  was  in  the  auditory  canal.  8  were 
in  the  cavity  of  the  tympanum,  and  3  in  the  Eustachian  tube 
Of  the  three  cases  in  the  Eustachian  tube,  two  were  at  the  pha- 

1  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  IV. ,  No.  1. 


198  FOREIGN    BODIES — CASES. 

ryngeal  orifice.  In  the  third  case,  a  barley-corn  projected  from 
the  pharyngeal  orifice,  and  at  the  post-mortem  section — it  is  not 
stated  of  what  disease  the  patient  died— the  foreign  body  was 
found  to  reach  into  the  osseous  tube. 

In  two  of  the  cases  the  foreign  body  was  in  the  ear  but  twelve 
hours  before  seen  by  the^  surgeon  who  reported  them.  In  only 
12  of  the  cases  was  the  foreign  body  in  but  a  short  time,  vary- 
ing from  days  to  weeks.  In  the  remainder  they  were  in  for 
years.  Four  were  in  for  four  years,  two  for  twenty  years,  one 
for  forty-five,  and  one  for  more  than  sixty  years. 

The  substances  found  were — a  needle,  carob  beans  (6),  beans 
(3),  cherry  pits  (6),  living  larvae  (4),  peas  (1),  a  wisdom  tooth  of 
the  upper  jaw,  a  grain  of  coffee,  a  snail,  pearls  (2),  point  of  a 
glass  syringe,  a  glass  ball,  wads  of  cotton  (C5),  a  carious  tooth,  a 
piece  of  hard  coal,  a  wad  of  paper,  a  gun  cap,  a  piece  of  bone, 
a  piece  of  bread,  a  bit  of  lead,  laminaria  bougies  in  the  tube  (2), 
a  millet  seed,  a  piece  of  coral,  a  barley-corn  in  the  tube,  and  an 
agate  stone. 

Dr.  Mayer  finds,  on  an  analysis  of  these  cases,  that  the  at- 
tempts to  remove  the  foreign  bodies  had  usually  caused  much 
more  trouble  in  the  ear  than  their  presence. 

In  48  of  the  77.  cases,  functional  and  pathological  changes  are 
said  to  have  occurred  as  a  result  of  the  presence  of  the  foreign 
bodies.  In  11  of  the  cases  it  is  reported  that  the  attempt  at  re- 
moval caused  these  disturbances. 

Pain  in  the  ear  was  generally  the  disturbing  symptom  in 
those  cases  in  which  the  foreign  body  caused  any  trouble.  This 
was  chiefly  due  to  the  irritation  of  the  lining  membrane  of  the 
canal,  which  is  so  closely  allied  to  periosteum  in  its  nature  as  to 
be  subject  to  intense  pain.  Besides,  as  shown  by  F.  E.  Weber, 
the  pain  in  the  cartilaginous  portion  of  the  canal  is  severe  on 
account  of  the  fact,  that  the  fibrous  tissue  of  the  cartilaginous 
canal  is  fastened  to  the  squamous  portion  of  the  temporal  bone, 
above  and  behind,  by  tense  fibres.  As  has  been  shown,  the 
canal  is  very  richly  supplied  with  nerves,  and  this  serves  to  ex- 
plain the  severe  pain  experienced  when  a  rough  body  is  in  the 
ear,  or  when  the  canal  is  abraded  by  attempts  at  the  removal 
of  a  smooth  and  harmless  one. 

Polypi  arose  five  times  in  consequence  of  the  inflammation 
of  the  ear.  Severe  hemorrhage  occurred  five  times,  and  always 
in  consequence  of  attempts  to  remove  the  foreign  bodies. 

In  one  case  there  was  delirium,  and  in  three  cases  suppura- 
tive  meningitis,  and  once  a  cerebral  abscess,  with,  of  course,  a 
fatal  result. 

The  membrana  tympani  was  perforated,  and  the  cavity  of 


FOREIGN    BODIES — CASES.  199 

the  tympanum  inflamed,  from  the  efforts  at  extraction  in  the 
three  cases  in  which  meningitis  resulted. 

In  one  case  the  patient,  a  child,  attempted  to  push  the  for- 
eign body — a  piece  of  flint-stone^cmf  through  the  other  ear. 
Suppurative  meningitis  occurred,  and  death  resulted  in  a  few 
days.  The  stone  was  so  firmly  fixed  in  the  mastoid  cells  that 
trouble  was  experienced  in 'removing  it,  even  at  the  post-mortem 
examination. 

In  one  case  on  the  section,  a  wad  of  paper  was  found  in  a 
cerebral  abscess  which  communicated  with  a  collection  of  pus 
in  the  tympanic  cavity.  It  had  probably  been  forced  there  by 
the  attempts  to  remove  it. 

The  disturbances  of  the  nervous  system  were  considerable  in 
some  cases,  and  they  throw  light  upon  the  influence  of  chronic 
aural  suppuration  upon  this  part  of  the  organism.  In  three 
cases  there  were  general  convulsions  ;  there  was  paralysis  of 
one  side  of  the  face  in  five  cases,  atrophy  of  the  arm  in  two 
cases,  twice  there  was  anaesthesia  of  the  whole  of  one  side  of 
the  body.  There  were  two  cases  of  epilepsy.  The  facial  paraly- 
sis was  caused  by  a  continuation  of  the  inflammation  to  the 
Fallopian  canal  and  the  facial  nerve. 

The  convulsions  and  the  epilepsy  were  probably  caused  by 
reflex  action  through  the  medulla  oblongata,  due  to  peripheric 
irritation  of  the  fifth  pair  of  nerves. 

The  cases  of  atrophy  of  the  arm  and  anaesthesia  of  the  body 
are  so  imperfectly  reported,  that  Mayer  does  not  attempt  any 
explanation  of  them. 

Our  limits  do  not  allow  of  a  complete  transcription  of  the 
cases  which  Dr.  Mayer  has  collected  with  such  care  ;  only  a  few 
of  the  more  curious  or  important  ones  can  receive  a  further 
allusion. 

In  one  case,  a  horse  coughed  some  oats  into  the  ear  of  a  man 
as  he  was  going  by  the  animal. 

Deleau,  Junior,  removed  a  foreign  body  from  the  cavity  of 
the  tympanum,  an  agate  stone,  by  an  injection  of  water  through 
the  Eustachian  tube.  The  reader  will  find  this  case  fully  re- 
ported in  Lincke's  collection  of  "  Monographs  on  the  Ear." 

The  case  of  atrophy  of  one  arm,  epilepsy,  anaesthesia  of 
one-half  of  the  body,  is  the  famous  one  of  Fabricius  Hildamis, 
quoted  by  Von  Troltsch.2  The  patient,  a  young  woman  of  eigh- 
teen years,  is  said  to  have  been  cured  of  all  these  symptoms  by 
the  removal  of  the  foreign  body,  a  glass  ball,  eight  years  after  it 

1  Lincke's  Sammlung,  Bd.  I.,  p.  154. 

2  Text-book,  American  translation,  p.  490. 


200  FOREIGN    BODIES — CASES. 

was  inserted.  (See  latter  part  of  this  chapter  for  a  full  account 
of  this  case.) 

Handfield  Jones '  saw  a  case  in  which  hemiplegia  with  con- 
vulsions arose  from  the  presence  of  insects  in  the  ear. 

Wederstrandt a  reports  a  case  in  which  molten  lead  was 
poured  into  the  right  ear  of  a  drunken  man.  The  pain  was  not 
severe  ;  the  hearing  power  was  gone.  The  patient  was  able  to 
leave  the  hospital  in  eight  days.  The  lead  was  not  removed, 
and  severe  suppuration  occurred.  Seventeen  months  after  he 
was  in  the  same  condition,  with  paralysis  of  the  right  orbicu- 
laris  palpebrarum  muscle  ;  a  polypus  had  grown  over  the  lead. 

In  three  of  the  cases  death  occurred,  and  in  all  of  them  it 
may  properly  be  said  to  have  been  caused  by  attempts  to  re- 
move foreign  bodies,  which,  whatever  disturbances  of  the  sys- 
tem they  might  have  produced,  would  not  probably  have  led  to 

death. 

• 

Mr.  Pilcher,  in  his  work  on  the  ear, "•  reports  a  very  instructive 
case  from  the  Lancet,  in  which  surgeons  of  a  London  hospital 
attempted  to  remove  from  the  ear  of  a  child  of  seven  years  of 
age,  the  head  of  a  nail,  which  they  never  saw,  but  which  they 
felt  with  a  probe. 

The  first  surgeon  to  whom  the  child  was  brought  said  he  saw 
the  head  of  the  nail,  but  he  did  not  attempt  to  remove  it  because 
four  men  could  not  hold  the  boy's  head  still.  A  director,  dress- 
ing forceps,  which  were  both  bent  in  the  forcible  efforts,  forceps 
with  hooks  were  used,  and  they  were  also  bent  straight,  but  the 
nail  could  not  be  removed.  An  incision  was  then  made  behind 
the  auricle,  and  the  meatus  was  exposed.  A  search  was  then 
made  for  the  nail,  with  forceps  and  an  elevator.  Tooth  forceps 
were  then  used;  three  pieces  of  metal,  which  appeared  to  be 
pieces  of  the  nail,  were  removed  by  these  delicate  instruments. 
The  malleus  bone  was  then  removed  by  the  forceps. 

The  patient  was  now  so  exhausted  that  "his  pulse  could 
scarcely  be  felt,  and  his  skin  was  bedewed  with  cold  perspira- 
tion." 

The  operator  then  stated  that  he  had  used  "more  force  than 
was  warrantable."  He  thought,  however,  there  was  now  a  large 
opening  (sic)  through  which  pus  might  escape,  and  yet  he  feared 
that  a  portion  of  the  petrous  bone  might  exfoliate,  and  that 
meningitis  and  abscess  of  the  brain  might  occur.  He  stated 

1  Sydenham  Society  Year-book,  1861. 
9  American  Journal  of  the  Medical  Sciences,  Vol.  IX. 

3  Treatise  on  the  Ear,  American  edition,  by  George  Pilcher.  Philadelphia,  1843- 
Reprint,  p.  219. 


FOREIGN    BOPIKS — CASKS.  201 

that  he  had  seen  three  or  four  cases  which  had  terminated  in 
this  manner.  Of  course  the  little  victim  died,  and  that  too  on 
the  third  day  after  these  operative  attempts. 

The  post-mortem  examination  revealed  softening  of  the  base 
of  the  brain,  and  of  the  anterior  part  of  the  hemispheres.  Not  a 
vestige  of  the  bony  part  of  the  external  auditory  canal  remained, 
it  having  been  removed  during  the  operation,  and  the  floor  of  the 
tympanum  was  also  wanting.  There  was  considerable  pus  in 
the  tympanic  cavity. 

"The  nail  not  being  in  the  tympanum,  sections  were  made 
through  the  cochlea,  vestibule,  semicircular  canals,  and  mastoid 
•cells;  but  there  was  no  nail  to  be  found" 

The  following  case,  also  belongs  in  this  sad  category  of  great 
•damage  done  by  unwise  attempts  to  extract  a  foreign  body. ' 

Extraction  of  a  Foreign  Body  from  the  Tympanum,  with  Resection  of  the  Tym- 
panic Ring. — The  following  case  is  related  in  the  Norsk  Magazin  for  Laeger- 
idenskaben,  vol.  xii.,  No.  11.  A  little  girl,  aged  four,  while  playing  on  the  sea- 
shore had  a  stone  pushed  into  her  ear  by  her  sister.  A  few  days  later,  upon  the 
sister's  confessing  her  trick,  the  mother  attempted  to  dislodge  the  stone  by 
means  of  a  hair-pin,  but  not  succeeding,  she  took  the  child  to  several  physicians, 
•one  after  the  other,  all  of  whom  made  repeated  unsuccessful  attempts  to  extract 
the  foreign  body.  It  was  then,  two  and  a  half  weeks  after  the  accident,  that  the 
<jhild  was  sent  to  the  Eigshospital  in  the  service  of  Dr.  J.  Nicolaysen.  Examina- 
tion showed  numerous  erosions  in  the  external  auditory  canal,  the  outer  two- 
thirds  of  which  was  swollen  and  ecchymotic,  the  inner  third  entirely  denuded  of 
•skin  and  periosteum.  The  drum-head  was  gone,  the  tympanic  ring  bare,  and  the 
cavity  of  the  tympanum  filled  up  by  the  foreign  body.  The  stone  seemed  to  be 
wedged  tightly  in  the  anterior  part  of  the  cavity.  There  was  some  purulent 
secretion  from  the  tympanum  and  meatus.  The  first  efforts  at  extraction  were 
unsuccessful,  and  the  operation  was  put  off  till  the  following  day  to  give  time 
for  the  manufacture  of  some  strong  hooks.  When  these  were  procured  they 
were  slipped  past  the  stone,  but  were  broken  off  and  their  points  left  in  the 
cavity  of  the  ear.  As  the  child  had  several  times  stopped  breathing  the  chloro- 
form was  withheld  and  the  operation  again  interrupted.  The  third  attempt  was 
successful.  A  very  fine  saw  was  introduced  and  two  notches  made  in  the  tym- 
panic ring,  one  directly  forward  and  the  other  downward.  Then  the  intervening 
section  of  bone,  about  one-fourth  of  an  inch  in  length,  was  knocked  off  with  a 
chisel.  The  stone  was  now  readily  extracted  and  with  it  the  broken  hooks  and 
ossicles.  The  stone  measured  8.75  mm.  in  length,  5.5  mm.  in  width,  and  4.75 
mm.  in  thickness.  The  well-meant  efforts  at  extraction  had  siicceeded  only  in 
wedging  it  in  the  tympanic  orifice  by  its  largest  diameter,  thereby  destroying 
the  drum-head  and  the  ossicles. 

The  fact  has  already  been  alluded  to  in  this  chapter,  that 
persons  sometimes  suppose  there  is  a  foreign  body  in  the  ear, 

1  Medical  Record,  vol.  xxv. ,  p.  208. 


202  FOREIGN   BODIES — DELUSIONS. 

when  there  is  actually  none  in  it,  and  when  there  probably 
never  has  been  one  there.  At  times  delusions  occur  on  this 
subject.  I  have  seen  several  cases  of  the  kind  which  are  quite 
remarkable. 

Two  cases  I  saw  at  the  New  York  Eye  and  Ear  Infirm- 
ary, where  the  patients,  who  were  women  of  the  lower  class 
of  life,  supposed  that  pins  were  in  the  auditory  canaL  No 
amount  of  reasoning,  nor  the  subterfuge  of  pretending  to  re- 
move a  pin  from  the  ear,  by  syringing,  could  satisfy  these 
females. 

In  another  case  a  woman  brought  her  son  to  my  clinic  in  the 
University  of  New  York,  and  stated  that  he  was  passing  pieces 
of  anthracite  coal  from  the  external  meatus.  She  had  quite  a 
quantity  of  coal  in  a  handkerchief,  which  she  said  had  been 
passed  from  the  ear.  Some  of  these  pieces  of  coal  were  larger 
than  the  auricle.  The  boy  agreed  with  his  mother  in  her  insane 
statements.  I  am  sorry  that  they  passed  from  my  observation 
before  I  could  fully  investigate  the  cause  or  motive  for  the  de- 
lusion. 

In  another  part  of  this  work '  allusion  will  be  again  made  to 
the  cases,  not  uncommon,  in  which  patients  with  chronic  disease 
of  the  middle  ear,  and  persons  who  perhaps  were  of  sound  mind, 
firmly  believed,  in  spite  of  the  negative  result  of  my  examina- 
tions, that  there  was  inspissated  cerumen  in  the  auditory  canal. 
Indeed,  the  sensation  of  fulness  of  the  canal  in  chronic  cases  of 
disease  of  the  middle  ear,  is  often  so  decided  as  to  render  such  a 
belief  pardonable,  in  a  person  who  has  not  full  confidence  in  the 
surgeon  who  examines  the  ear. 

It  has  been  mentioned,  in  the  second  chapter,  that  the  hairs 
of  the  auditory  canal  sometimes  lie  on  the  drum-head,  and  thus 
become  irritating  foreign  bodies. 

We  see  from  all  this,  that  it  is  by  gentle  manipulations,  made 
with  delicate  instruments,  under  the  guidance  of  personal  skill 
and  ingenuity,  that  these  cases  are  to  be  managed.  An  eminent 
artist  was  once  very  earnestly  inquired  of  by  an  amateur,  as  to 
what  he  mixed  his  colors  with.  His  answer  was,  "  With  brains, 
sir !"  Perhaps  nowhere  in  surgery,  does  this  old  anecdote  better 
illustrate  the  necessity  of  using  instruments  with  brains,  than  in 
the  removal  of  foreign  bodies  from  the  ear. 

The  conclusions  to  which  I  have  come,  as  to  the  mode  of  a 
procedure  in  cases  of  suspected  foreign  bodies  in  the  ear,  may 
be  formulated  as  follows  : 


Chapter  on  Chronic  Non-suppurative  Inflammation. 


FOREIGN   BODIES.  203 

1.  Assure  one's  self  by  ocular  examination  of  the  presence  of 
the  foreign  body. 

2.  Try  syringing  with  a  large  syringe  with  a  small  nozzle,  the 
patient  being  placed  in  various  positions,  according  to  the  situa- 
tion of  the  body. 

3.  If  this  fail,  use  a  Daviels'  spoon,  a  wire  loop,  a  bent  probe, 
a    cystotome   used   by  oculists,    or   the   like,   and   attempt  to 
change  the  position  of  the  foreign  body,  so  that  the  stream 
of  water  can  get  behind  it  and  force  it  out.    This  displacement 
should  generally  be  done  under  ether,  especially  in  the  case 
of  children  who  have  been   frightened  by  previous  attempts 
at  removal. 

4.  If  the  foreign  body  be  so  wedged  in  that  this  method  fails, 
Lowenburg's  gluing  procedure,  Elsberg's  instrument,  or  some 
one  of  the  numerous  aural  forceps,  are  worthy  of  use. 

5.  If  no  urgent  symptoms  occur,  and  these  attempts  at  removal 
have  caused  excoriation  and  inflammation  of  the  auditory  canal, 
wait  until  they  have  subsided,  meanwhile  syringing  the  ear  with 
warm  water  several  times  a  day. 

6.  If  all  ordinary  and  safe  procedures  through  the  meatus 
have  failed,  separate  the  auricle  and  get  at  the  foreign  body 
from  behind. 

7.  In  a  case  where  there  are  no  symptoms  of  injurious  effects 
from  the  presence  of  a  foreign  body,  do  not  act  hastily  !  but  re- 
assure the  patient's  family,  that  no  clanger  will  result  from  delay, 
and  wait  until  proper  means  can  be  taken  to  safely  remove  the 
offending  substance.    It  is  very  seldom,  indeed,  that  there  is  any 
urgency  in  the  case,  except  in  the  minds  of  the  friends  of  the 
generally  infantile  patient. 

FOREIGN   BODIES   IX  THE  EUSTACHIAX   TUBE. 

Among  the  cases  whose  statistics  are  reported  by  Dr.  Mayer, 
two  will  be  noticed  where  laminaria  bougies  were  broken  off  in 
the  Eustachian  tube.  Dr.  Hecksher,  of  Hamburg,  relates  an 
interesting  case  that  belongs  to  this  class.  The  patient  was  a 
principal  of  a  college,  who  had  been  accustomed  to  treat  his 
own  ears — which  were  affected  with  chronic  catarrh — by  the 
use  of  the  Eustachian  catheter. 

Dr.  Hecksher  received  a  telegram  one  day  from  the  pa- 
tient, for  whom  he  had  occasionally  prescribed,  stating  that 
he  had  got  a  foreign  body  in  one  of  his  Eustachian  tubes. 
When  Dr.  Hecksher  reached  the  patient,  he  gave  the  following 
history  : 

He  had  introduced  through  a  metallic  catheter  a  whalebone 


204  FOREIGN   BODIES — EAR-COUGH. 

probe  into  the  tube.  On  the  end  of  this  probe  was  fastened  with 
a  silk  thread  a  raven's  feather,  which  he  used  for  the  purpose 
of  washing  away  mucus  from  the  tube. 

One  evening  as  he  was  using  the  apparatus,  he  drew  back 
the  probe  without  the  feather,  and  he  found  that  he  had  left  it 
in  the  tube.  It  caused  so  much  pain  that  he  could  not  sleep. 
Attempts  were  made  by  a  physician  to  remove  the  foreign  body, 
bu'  they  failed.  Dr.  Hecksher  then  attempted  to  remove  the 
bo^y,  but  the  parts  were  so  swollen  that  he  could  not  practise 
rhinoscopy,  and  see  the  feather,  and  he  failed  with  various 
kinds  of  forceps  to  remove  it. 

So  much  inflammation  ensued  that  he  was  obliged  to  de- 
sist, and  use  antiphlogistic  treatment ;  but  the  patient  finally 
removed  the  feather  himself  by  the  aid  of  the  catheter  in- 
troduced in  the  usual  way,  and  his  finger  passed  behind  the 
uvula. 

Politzer '  also  relates  two  cases,  quoted  from  Urbantschitsch 
and  Schalle,  where  foreign  bodies  have  reached  the  cavity  of 
the  tympanum  from  the  pharynx.  The  first  was  an  oat  husk, 
which  had  stuck  in  the  throat  in  chewing  an  ear  of  grain..  It 
entered  the  Eustachian  tube  and  the  tympanic  cavity,  and  came 
through  the  external  meatus. 

In  Schalle's  case  a  piece  of  hard  rubber  syringe,  employed  in 
douching  the  nose,  broke  off,  and  entered  the  tube  and  tym- 
panum. In  the  drum  cavity  it  caused  acute  suppuration,  and 
was  removed  by  incision  of  the  membrane. 

EAR-COUGH. 

Every  practitioner  who  has  been  at  all  in  the  habit  of  ex- 
amining ears,  must  have  observed  a  cough  which  occurs  in 
many  patients,  whenever  a  certain  part  of  the  auditory  canal 
is  touched  by  a  cotton -holder,  a  probe,  or  the  like.  There  is- 
the  greatest  variation  in  the  sensitiveness  of  patients  in  this 
regard.  Some  of  them  scarcely  tolerate  any  contact  with  the 
osseous  canal  without  responding  by  a  cough,  while  others, 
and  by  far  the  greater  number,  during  a  long  course  of  treat- 
ment never  exhibit  any  disposition  to  cough  when  the  canal  is 
touched. 

Certain  other  reflex  symptoms  from  irritation  of  the  walls 
of  the  canal  have  been  observed  for  centuries.  Such  are  sneez- 
ing and  vomiting,  and  even  epileptic  seizures.  For  example, 
Troltsch"  quotes  from  Pechlin,  who,  writing  in  1691,  says  he 

1  Text-book,  English  translation,  p.  631. 
9  Lehrbuch,  Sechste  Auflage,  p.  522. 


EAR-COUGH.  205 

knew  a  man  in  whom  contact  with  the  external  auditory  canal 
always  caused  vomiting.  Arnold,1  also  quoted  by  Troltsch,  tells 
a  story  of  a  now  famous  girl,  who  suffered  for  a  long  time  from 
a  severe  cough  and  expectoration,  who  besides  often  vomited 
and  gradually  became  very  thin,  and  who  was  finally  relieved 
from  all  her  symptoms  by  the  removal  of  a  bean  from  each  ear. 
Arnold  relates  another  case  where  a  "  disease  of  the  chest "  was 
cured  by  the  removal  of  a  foreign  body  from  the  ear.  Toynbee  *• 
also  records  the  case  of  a  patient,  who  suffered  from  a  cough 
which  no  treatment  subdued,  until  a  portion  of  dead  bone  was 
removed  from  the  auditory  canal.  The  most  important  of  all 
the  cases  of  reflex  symptoms  from  irritation  of  the  external 
canal  of  the  ear  yet  reported,  is  that  of  Fabricius,  of  Hilden, 
whose  case  Troltsch  also  quotes.  A  girl  of  ten  years  of  age. put 
a  small  glass  ball  in  her  ear.  Many  attempts  were  made  to  re- 
move it,  but  they  were  unsuccessful.  Finally  she  was  seized 
with  hemicrania,  anaesthesia  of  the  entire  left  side  of  the  body, 
alternating  with  severe  pain,  until  at  last  epileptic  attacks  oc- 
curred, with  atrophy  of  the  left  arm.  At  eighteen  years  of  age 
she  came  under  the  care  of  Fabricius,  who  drew  out  the  story 
of  the  glass  bead,  which  had  been  well-nigh  overlooked,  since 
she  never  complained  of  earache.  He  removed  the  foreign  body 
and  cured  the  patient  of  all  her  troubles,  as  he  writes  to  his 
friend  Bauhinus,  " Restituum  est  quoque  brachium." 

Schwartze  and  Koeppe 3  also  speak  of  reflex  phenomena  from 
foreign  bodies  in  the  canal.  Koeppe,4  in  an  article  upon  "Re- 
.flex  Psychosis  from  Aural  Diseases,"  relates  two  cases  where 
treatment  of  the  hose,  throat,  and  ears  restored  the  patients  to 
sound  mental  condition.  In  the  first  case  there  was  ozaena  and 
catarrh  of  the  ears  ;  in  the  second  hardened  blood  was  removed 
from  the  auditory  canal,  where  it  had  remained  for  years,  as 
the  result  of  a  hemorrhage  from  a  fall,  or  several  falls,  upon  the 
head.  These  cases  are  exceedingly  interesting. 

Dr.  Kupper 6  reports  a  case  of  epilepsy  from  a  foreign  body 
in  the  auditory  canal,  and  also  a  case  of  cerebral  irritation  from 
inspissated  cerumen. 

A  young  woman  of  eighteen  was  admitted  to  the  hospital  with  the  following 
history  :  She  had  had  severe  pain  in  the  right  ear,  and  suppuration  had  finally 
occurred.  Toothache  also  set  in  later,  when  she  put  a  piece  of  a  root  in  the 


1  Loc.  cit. 

2  Treatise  on  the  Ear,  English  edition,  p   39. 

3  Archiv  filr  Ohrenheilkunde,  Bd.  V.,  S.  283. 

4  Ibid.,  Bd.  IX.,  p.  220. 

6  Ibid.,  Bd.  XX.,  p.  167. 


206  EPILEPSY    FROM    FOREIGN    BODY. 

suppurating  ear  to  relieve  the  pain.  She  was  not  able  to  remove  it,  and  since 
that  time  she  had  suffered  from  epileptic  seizures.  They  often  occurred  daily 
and  sometimes  several  times  a  day.  An  examination  showed  the  young  woman 
to  be  well  except  as  to  the  right  ear.  The  tuning-fork  was  heard  better  on  that 
side,  the  watch  was  only  heard  when  laid  upon  the  ear.  The  auditory  canal  was 
sensitive  on  pressure,  and  full  of  pus.  Careful  syringing  caused  vomiting  and 
vertigo.  The  canal  was  filled  with  polypi  that  were  very  sensitive.  The  pa- 
tient was  put  under  the  influence  of  chloroform,  and  the  polypi  were  removed. 
On  the  next  day  the  foreign  body  was  removed  with  a  blunt  hook  and  syring- 
ing, the  patient  being  again  under  the  influence  of  chloroform.  The  piece  of 
wood  was  1  cm.  long  and  f  cm.  thick.  Only  two  attacks  of  epilepsy  occurred 
after  the  operations,  one  within  a  few  hours  of  the  last  operation,  the  other  two 
days  after.  The  patient  also  recovered  full  hearing  power. 

The  second  patient  was  a  woman  of  seventy-six,  who  suddenly  began  to  have 
cerebral  symptoms,  headache,  vertigo,  vomiting,  severe  spasm  of  the  muscles  of 
the  face  and  of  the  extremities.  She  especially  complained  of  pain  in  the  right 
ear,  and  it  was  found  to  be  sensitive  on  contact.  The  organs  of  the  old  lady 
were  found  to  be  in  good  condition,  except  the  right  auditory  canal,  which  was 
completely  stopped  by  wax.  The  mass  was  removed  with  great  difficulty  in 
about  two  days,  after  softening  it.  The  necessaiy  manipulations  caused  serious 
symptoms,  but  as  soon  as  the  wax  was  loosened  they  disappeared.  The  mem- 
brana  tynipani  was  found  to  be  the  seat  of  old  disease,  and  was  adherent  to 
the  promontory.  There  was  no  hearing-power  on  that  side.  In  six  weeks  the 
patient,  who  was  much  run  down  by  her  symptoms,  had  fully  recovered  and  was 
able  to  go  out. 

Wilde1  also,  quotes  from  Dr.  Maclagan  "a  case  of  epilepsy 
and  deafness,  dependent  on  the  presence  of  a  foreign  body  in 
the  ear."  After  the  seed  of  a  sycamore,  which  had  been  in  the 
ear  ten  years,  was  removed,  the  epileptic  attacks  ceased,  and 
the  deafness  declined.  Sir  William  seems  to  have  been  some- 
what skeptical  about  this  case,  and  he  says:  "I  must  confess 
that  I  am  inclined  to  bring  in  the  Scotch  verdict  of  'non 
proven,'  as  far  as  the  seed  is  concerned.  The  state  of  the  ear, 
either  before  or  after  the  removal  of  the  foreign  body,  has  not 
been  recorded ;  nor  whether  the  seed  ruptured  the  membrana 
tympani,  or  caused  any  disorganization  of  the  parts."  Wilde 
goes  on  to ,  say,  that  if  the  introduction  of  a  foreign  body  into 
the  canal  causes  epilepsy,  it  must  be  by  pressing  upon  the  sen- 
sitive part  which  he  had  met  in  some  persons,  in  syringing  the 
ear.  He  was  not  able  to  explain  the  phenomenon,  but  later  on 
in  his  book  he  quotes  another  writer,2  who  explains  it  by  hyper- 
sesthesia  of  the  auricular  branch  of  the  pneumogastric.  Strange 
to  say,  there  remains  a  doubt,  from  the  varying  statements  of 
anatomists,  as  to  whether  the  auditory  canal  is  or  is  not  sup- 

1  Aural  Surgery,  p.  189. 
2Loc.  cit.,  p.  326. 


BRANCH    OF    PNEUMOGASTRIC    IN    EAR.  207 

plied  by  the  pneumogastric.  Quain  '  only  speaks  of  the  auricu- 
lar branch  of  the  pneumogastric  as  supplying  "the  integument 
of  the  back  of  the  ear." 

Sappey 2  describes  it  as  supplying  the  canal,  as  do  other  au- 
thors, for  example,  Gruber,3  who  says  :  "  The  auricular  branch 
of  the  vagus  extends  not  only  to  the  posterior  surface  of  the 
auricle,  but  also  to  the  cartilaginous  part  of  the  auditory  canal. 

Troltsch 4  also  describes  an  auricular  branch  of  the  vagus 
which,  as  he  says,  enters  the  posterior  part  of  the  osseous  canal. 
This  acceptance  of  Arnold's  discovery  of  the  auditory  branch  of 
the  pneumogastric  is  usually  accepted,  although  the  most  com- 
plete article  on  ear-cough  of  which  I  know,  that  by  Cornelius 
B.  Fox,6  agrees  with  Quain,  that  the  auricular  branch  of  the 
pneumogastric  only  supplies  the  posterior  part  of  the  pinna  (au- 
ricle). In  about  twenty  per  cent,  of  the  persons  examined  by  Dr. 
Fox  there  was  found  a  hypersesthetic  state  of  the  nerve  supply- 
ing the  auditory  canal,  that  is,  they  were  persons  in  whom  any 
slight  titillation  of  the  nerve  produced  a  sense  of  tickling  in  the 
throat.  These  are  the  persons  alluded  to  in  the  opening  sen- 
tences on  this  subject  in  this  book.  Dr.  Fox  also  believes,  that 
when  this  condition  exists,  it  is  a  congenital  peculiarity,  and  that 
the  connection  between  the  nerves  involved  takes  place  in  the 
brain.  The  cases  of  ear-cough  cited  by  Fox  are  similar,  and  in 
some  instances  identical,  with  those  I  have  enumerated.  There 
is  no  attempt  made  to  trace  cough  to  evanescent  or  temporary 
influences,  such  as  cold  upon  the  face  and  auditory  canal.  In 
the  two  cases  of  his  own  cited  by  Fox,  in  the  one  instance  the 
cough  was  caused  by  wax  and  an  ulcer  of  the  canal ;  in  the 
other,  by  an  inflammation  of  the  canal  produced  by  the  use  of  a 
spirituous  irritant.  Lockart  Clarke 6  supports  Fox's  view  as  to 
the  origin  of  ear-cough,  "in  the  fibres  of  the  fifth  cerebral  nerve 
distributed  to  the  auditory  canal."  Mr.  John  Wood,7  an  examiner 
in  anatomy  of  the  University  of  London,  states  positively  that  he 
has  traced  a  branch  of  the  vagus  into  the  auditory  canal,  "pass- 
ing through  a  minute  foramen  between  the  jugular  fossa  and 
the  glenoid." 


1  Elements  of  Anatomy,  eighth  edition,  p.  560. 

•  Traite  d' Anatomic,  Tome  III.,  p.  842.  1877.  "La  peau  du  conduit  externe  est 
extrtmement  sensible.  .  .  .  soit  enfin  au  rameau  auriculaire  de  pneumogastrique, 
qui  vient  se  perdre  dans  la  pean  de  la  portion  osseuse  du  conduit." 

3  Lehrbuch,  p.  144. 

4  Ibid.,  VI.  Aufgabe,  p.  29. 

5  British  Medical  Journal,  December  18,  1869,  p.  650. 

6  Ibid.,  1870,  p.  51. 
7Loc.  cit.,  p  328. 


WOAKES   ON  EAR-COUGH. 

From  the  facts  so  well  established  since  the  time 'of  Fabricius, 
theoretical  writers  have  made  the  most  possible.  Woakes1  seems 
hardly  to  consider  them  exceptional,  and  argues  with  ingenuity, 
but  I  cannot  think  soundly,  that  there  may  be  quite  a  large  class 
of  cases  of  affections  of  the  larynx,  that  are  due  to  auditory  irri- 
tation. He  suggests  spasmodic  croup  as  occasionally  owing  its 
origin  to  a  draught  of  cold  air  falling  upon  the  ear.  He  also 
attempts  to  explain  "derangement  in  the  in  nervation  of  the 
laryngeal  muscles "  as  possibly  due  to  reflex  influence  from  the 
auditory  branch  of  the  vagus.  He  instances  the  coachman  ex- 
posed to  east  wind  and  rain,  and  who  finds  his  voice  "  husky, 
shrill,  or  faltering"  in  the  evening,  and  he  argues  that  the  excit- 
ing causes  are  draughts  of  cold  air  and  wet  upon  the  surface 
"the  impression  of  which,  is  conveyed  by  the  afferent  vaso-motor 
nerves  associated  with  the  cerebro-spinal  nerves  of  the  surface 
receiving  the  chill,  to  the  sympathetic  ganglion  with  which  they 
communicate  :  in  this  instance,  the  superior  cervical  ganglion." 
Dr.  Woakes  traces  the  irritation,  1,  from  the  vaso-motor  fibres 
associated  with  the  auricular  branch  of  the  pneumogastric ;  2,  to 
the  secondary  vaso-motor  centre,  the  ganglion  of  the  pneumogas- 
tric, whence  he  says  it  is  deflected  through  a  sympathetic  fasci- 
culus to  the  first  cervical  ganglion  ;  3,  thence  by  the  nervi  molles 
to  the  vessels  distributed  to  the  mucous  membrane  of  the  larynx. 
He  rejects  the  simple  idea  that  the  morbid  impression  is  con- 
ducted along  the  sensitive  fibres,  from  one  region  to  another. 

Orne  Green8  suggests  in  a  review  of  Dr.  Woakes'  book  quoted 
by  Woakes  himself,  that  the  mechanical  commotion  of  the  larynx 
caused  by  the  cough,  is  the  cause  of  the  local  inflammatory  mis- 
chief in  this  organ.  The  subject  is  an  interesting  one,  but  the 
cases  of  reflex  phenomena  from  irritation  of  the  canal  are  too 
infrequent,  in  my  opinion,  to  justify  the  deductions  of  Woakes  in 
regard  to  laryngeal  paresis,  and  subsequent  inflammation.  Dr. 
Woakes  quotes  an  amusing  story,  from  Miss  Edgeworth's  tales, 
which  will  bear  repetition  :  This  author  relates  that  a  choking 
Norwegian  clergyman  at  a  feast,  was  relieved  by  a  blast  of  air 
from  a  bellows,  which  a  friendly  companion  blew  into  his  ear. 
"  The  effect  was  magical :  the  expulsive  action  of  the  laryngeal 
muscles,  called  into  play  by  this  novel  method,  speedily  got  rid 
of  the  food  which  the  gluttonous  haste  of  the  pastor,  had  caused 
to  go  the  wrong  way." 

Woakes 3  points  out  that  sneezing  caused  by  irritation  of  the 


1  Deafness,  Giddiness,  and  Noises  in  the  Head,  p.  74  et  seq. 
*  Boston  Medical  and  Surgical  Journal,  1879,  p.  911. 
a  Loc.  cit.,  p.  93. 


EAR-COUGH.  209 

auditory  canal,  cannot  be  due  to  or  explained  by  referring  it  to 
"an  irritation  of  the  third  branch  of  the  fifth  nerve  exciting  the 
motor  laryngeal  branches  of  the  vagus,  through  communications 
existing  between  the  roots  of  these  nerves,"  as  claimed  by  Fox, 
Clarke,  and  Russell,  because  with  the  act  of  sneezing,  the  vagus, 
as  a  motor  nerve,  can  have  nothing  to  do. 

These  cases  are,  I  believe,  rare  and  exceptional,  and  I  am 
not  ready  to  accept  Dr.  Woakes'  theories  of  laryngeal  paresis 
and  cough,  or  to  believe  that  we  have  any  but  very  infrequent 
occasion,  to  refer  to  the  auditory  canal  for  the  explanation  of 
coughs.  When  this  theory  was  first  promulgated  in  this  coun- 
try, I  was  called  to  see  a  child  of  six.  months  of  age,  who  suf- 
fered from  persistent  cough.  I  was  asked  to  examine  the  ear 
to  explain  the  trouble.  But  while  the  history  showed  that  the 
child  had  recently  had  pleuro-pneumonia,  the  ears  revealed 
nothing  abnormal.  The  cough  in  this  case  may  easily  have  been 
due  to  pleural  adhesions.  I  only  mention  the  case,  to  show  how 
ready  we  all  are  to  give  up  obvious  and  simple  explanations,  to 
search  for  those  that  are  recondite. 

Ear-cough  is  a  very  uncommon  disease ;  when  it  does  occur, 
we  may  usually  find  an  obvious  local  cause  for  it  in  the  audi- 
tory canal,  as  in  the  classical  cases,  such  as  a  foreign  body 
or  inspissated  cerumen.  To  trace  any  considerable  number  of 
laryngeal  affections  to  transient  impressions  on  the  auditory 
canal,  to  impressions  that  act  more  directly  upon  other  parts 
of  the  surface  of  the  body,  is  to  go  beyond  the  bounds  of  what 
seems  to  me  logical  reasoning.  To  produce  ear-cough,  we  must 
have  a  continuously  acting  irritant.  I  do  not  deny  that  a  blast 
of  air  upon  an  auditory  canal,  in  cases  such  as  make  up  the 
twenty  per  cent,  contingent  of  Dr.  Fox's  tables,  may  produce 
ear-cough,  but  withdraw  the  draught,  and  the  cough  will  cease, 
just  as  it  does  when  the  bean,  or  wax,  or  probe  is  removed  from 
the  ear.  It  seems  to  me,  very  unlikely  that  a  permanent  lesion 
is  produced  by  such  a  temporary  influence. 


14 


THE   MIDDLE   EAR. 


CHAPTER  IX. 

ANATOMY  OF  THE  MIDDLE  EAB. 

Statistics  of  Diseases  of  the  Middle  Ear. — Membrana  Tympani. — Shrapnell's  Mem- 
brane. — Bivinian  Foramen.  — Light  Spot.  — Layers.  — Blood- Vessels.  — Nerves.  — 
Lymphatics. — Cavity  of  the  Tympanum. — Scheme  for  Studying  Boundaries  of  this 
Cavity.  — Ossicula  Auditus.  — Blood-Vessels.  — Nerves.  — Mastoid  Process.  — Eusta- 
«hian  Tube,  Historical  Account  of. — Physiology  of  the  Middle  Ear. 

BY  far  the  greater  number  of  aural  diseases  affect  what  is 
known  as  the  middle  ear.  Of  4800  cases,  occurring  in  my  pri- 
vate practice,  3673  were  diseases  that  involved  these  parts 
chiefly. 

Biirkner,  in  his  statistical  tables,  already  quoted,  in  a  total 
number  of  58,645  cases,  places  39,238  in  the  category  of  diseases 
of  the  middle  ear.  This  makes  a  percentage  of  nearly  70.  My 
own  statistics  exhibit  a  percentage  of  more  than  70.  Those  of 
the  Manhattan  Eye  and  Ear  Hospital  for  thirteen  years,  more 
than  76  in  a  hundred.  Of  a  total  of  10,335  cases,  7957  were  af- 
fections of  the  middle  ear.  It  is  probable  that  a  more  exact 
knowledge. will  in  the  future  diminish  this  proportion  somewhat. 
I  believe  that  it  will  yet  be  found,  that  diseases  of  the  labyrinth 
and  of  the  trunk  of  the  acoustic  nerve,  are  more  frequent  than 
is  now  supposed.  However  this  may  be,  the  diseases  of  the 
middle  ear,  will  probably  always  far  exceed  in  number  those 
of  the  other  parts  of  the  organ.  The  anatomy  of  this  region, 
therefore,  demands  a  careful  and  exact  study. 

By  the  term  middle  ear,  we  mean  the  membrana  tympani, 
the  cavity  of  the  tympanum,  the  mastoid  cells,  and  the  Eusta- 
chian  tube. 

THE  MEMBRANA  TYMPANI. 

The  membrana  tympani,  or  drum-head,  forms  the  boundary 
between  the  external  and  middle  ear.  It  partakes  of  the  char- 
acteristics of  these  two  parts,  in  being  composed  of  integument 
and  mucous  membrane,  while  it  has  one  structure — the  middle 
or  fibrous  layer— that  is  peculiar  to  itself. 


214  MEMBRANA  TYMPANT. 

The  upper  border  of  this  membrane  lies  7  mm.  nearer  to  the 
entrance  of  the  external  auditory  canal  than  the  lower.  The 
posterior  border  is  about  5  mm.  nearer  this  entrance,  or  mea- 
tus,  than  the  anterior.  The  angle  that  the  membrana  tympani 


FIG.  52. — The  Right  Temporal  Bone,  without  the  Petrous  Portion,  in  connection  with 
the  Ossicula  Auditus  of  a  Newly-born  Child,  seen  from  within  (after  Rudinger).1  4,  Is  above 
the  incus,  whose  short  process  is  directed  nearly  horizontally  backward ;  5,  the  long  arm  of 
the  incus,  which  extends  freely  into  the  cavity  of  the  tympanum  ;  6,  the  malleus,  in  articu- 
lation with  the  incus  ;  7,  long  process  of  the  malleus,  which  runs  under  the  crista  tympanica, 
in  a  furrow,  to  the  fissura  petroso-tympanica  ;  8,  the  stapes,  in  articulation  with  the  incus. 

makes  with  the  axis  of  the  auditory  canal,  is  one  of  about  55°. 
The  inclination  of  the  two  membranes  to  an  angle  opening  up- 
ward is  one  varying  from  130°  to  135°.  In  the  newly  born  it  was 
formerly  supposed,  that  the  membrana  tympani  lies  more  hori- 


PIG.  53. — Left  Temporal  Bone  of  the  same  Subject  as  preceding  Figure. 

zontally  than  in  the  adult,  and  that  it  is  almost  in  the  same  line 
with  the  upper  wall  of  the  external  auditory  canal. 

According  to  Pollak,  quoted  by  Politzer,'  this  is  incorrect. 

1  Atlas  des  Menschlicheii  Gehororganes.     Munchen,  1867. 
»  Text-book,  translation,  p.  20. 


MEMBRANA   TYMPANI. 


215 


Pollak  has  made  numerous  measurements,  and  he  states  that 
there  is  no  perceptible  difference  between  the  inclination  of  the 
membrane  of  the  newly  born  and  that  of  the  adult. 

The  peculiar  manner  in  which  the  membrana  tympani  is 
placed  in  the  canal,  causes  it  to  form  an  acute  angle  with  the 
lower  and  anterior  wall  of  the  auditory  canal,  but  an  obtuse  one 
with  the  upper  and  posterior  wall. 

The  general  shape  of  the  membrane  'is  elliptical ;  but  the 


FIG.  54. — Section  through  Tympanic  Cavity,  Left  Side  (actual  size,  anterior  half).  1, 
Squamous  portion  of  temporal  bone ;  2,  mastoid  cells ;  3,  membrana  tympani ;  A,  A, 
chorda  tympani ;  5,  aqueductus  Fallopii ;  6,  incus  (body)  ;  7,  malleus  (handle) ;  8,  Eusta- 
chian  tube  ;  9,  fossae  (middle  cerebral) ;  10,  groove  for  meningeal  artery. 


regularity  of  the  ellipse  is  broken  in  upon  by  the  incomplete- 
ness of  the  bony  ring  surrounding  the  membrane.  In  the  upper 
part  of  this  bony  ring  an  oval  section  is  wanting ;  this  space  is 
known  as  the  segment  of  Rivini. 

The  long  axis  of  this  ellipsoid  runs  downward  and  forward, 
the  shorter  backward  and  downward.  If  the  diameters  of  the 
membrane  are  measured  in  the  direction  of  the  axis  of  the  ellip- 
soid, that  of  the  long  axis  is  9.5-10  mm.,  and  the  horizontal  is 


216  SHRAPNELL'S  MEMBRANE. 

8  mm.  Measured  in  the  usual  manner,  the  horizontal  diameter 
is  8-8.5  mm.,  and  the  vertical  8.5-9  mm. 

The  Rivinian  segment  is  filled  by  the  tissue  of  the  cutis  and 
the  mucous  membrane  of  the  tympanic  -cavity.  The  greater 
part  of  the  fibres  of  the  tendinous  ring  of  the  membrana  tym- 
pani  bend  from  their  former  course,  and  at  this  point  turn 
toward  the  short  process  of  the  malleus,  which  lies  more  deeply 
where  it  is  inserted.  The  remainder  of  the  tendinous  fibres  of 
the  ring  pass  upward,  and  are  lost  in  the  connective  tissue  of 
the  periosteum. 

This  causes  an  irregular  triangular  space  to  be  formed, 
bounded  above  by  the  Rivinian  segment,  and  on  each  side  by 
two  bands,  which  attach  the  apex  of  the  small  process  of  the 
malleus,  to  the  anterior  and  posterior  corners  of  the  osseous 
groove. 

This  space,  and  the  tissue  filling  it,  was  first  described  by 
Mr.  Henry  Jones  Shrapnell,1  and  named  by  him  the  membrana 
flaccida.  It  is  often  called  Shrapnell's  membrane.  Mr.  Shrap- 
nell considered  that  the  function  of  this  flaccid  membrane  was 
to  protect  the  more  tense  fibres  during  the  effects  of  sudden  and 
loud  sounds,  or  the  actions  of  coughing  and  sneezing,  when  by 
yielding  it  saves  the  tense  fibres  from  being  ruptured.  In  the 
hare  and  the  sheep,  that  would  be  otherwise  defenceless  animals, 
were  it  not  for  the  great  power  of  their  ears  to  warn  them  of 
approaching  dangers,  this  structure  is  remarkably  developed. 

The  tissue  composing  Shrapnell's  membrane  is  less  tense  than 
the  remainder  of  the  membrana  tympani,  and  sometimes  falls  in 
like  a  pouch  toward  the  tympanic  cavity.  It  consists  of  a  very 
thin  layer  of  cutis  and  of  mucous  membrane.  The  mucous 
membrane  extends  to  the  osseous  edge  of  the  Rivinian  segment, 
and  from  here  passes  over  to  the  projecting  neck  of  the  malleus 
bone,  which  lies  opposite. 

The  existence  of  a  minute  opening  in  the  membrane — the  so- 
called  Rivinian  foramen — has  been  warmly  disputed  from  the 
time  of  its  discovery,  1717,  by  Rivinus,"  a  professor  in  Leipsic, 
until  the  present  day.  Professor  Patruban,3  of  Vienna,  found 
such  an  opening  in  300  membranes,  part  of  which  were  healthy, 
part  diseased.  He  allowed  a  fine  stream  of  quicksilver  to  pass 

1  London  Medical  Gazette,  vol.  10,  p.  120.  Several  German  authors  speak  of  Shrap- 
nell as  Odo  Shrapnell ;  but  his  name,  as  it  appears  in  the  original  of  his  articles,  is  as 
here  given.  • 

8  According  to  Von  Troltsch,  the  so-called  foramen  of  Rivinus  was  first  discovered 
by  Glaser,  in  1680,  who  was  then  professor  in  Basle.  Bochdalek,  however,  claims  the 
discovery  for  Colle. 

3  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  1. 


RIVINIAN   FORAMEN.  217 

into  the  so-called  canal,  and  it  always  appeared  on  the  other  side 
of  the  membrana  flaccida. 

Professor  Joseph  Gruber1  has  also  found  the  foramen  in  many 
specimens.  Inasmuch  as  he  oftener  found  it  in  pathological 
specimens,  he  thinks  that  its  size  is  at  least  increased  by  disease. 
Gruber  does  not  believe  that  it  is  an  opening  always  to  be  found ; 
but  that  it  is  one  frequently  observed,  and  that  it  would  be  an 
interesting  inquiry  as  to  how  far  it  is  the  result  of  disease. 

Politzer2  thinks  that  the  Rivinian  foramen  is  a  constant  ap- 
pearance, not  an  anomaly  or  result  of  disease. 

Hyrtl 8  denies  the  existence  of  the  foramen,  and  says  that 
he  has  never  found  it,  either  on  the  adult  or  infantile  cadaver. 
The  ability  to  blow  tobacco-smoke  from  the  ears  is  the  result,  he 
thinks,  of  a  want  of  development  in  the  upper  part  of  the  mem- 
brane. 

Professor  Bochdalek,  of  Prague,  rediscovered  the  opening  at 
the  upper  margin  of  the  membrana  tympani,  one-third  to  three- 
fourths  of  a  line  from  the  edge,  and  reopened  the  discussion 
which  Hyrtl  seemed  to  have  closed. 

If  the  Rivinian  foramen,  or  canal,  does  exist  in  the  membrana 
flaccida,  it  is  so  small  that  only  a  fine  bristle,  or  hair,  will  pass 
in  it,  and  the  anatomist  must  sometimes  persevere  for  hours  with 
a  magnify  ing-glass,  in  order  to  find  it.  Bochdalek4  describes  his 
discovery  of  the  opening  as  follows  :  "To  my  great  astonishment 
,1  saw,  by  means  of  a  magnifying-glass,  on  the  posterior  portion 
of  a  small  depression  on  the  membrana  tympani,  and  a  little  be- 
hind the  malleus,  a  very  small  canal,  in  which  was  perceived, 
although  very  indistinctly,  a  punctiform  opening.  By  means  of 
a  very  fine  bristle  I  succeeded  in  entering  a  narrow  groove,  not 
more  than  one-third  of  a  line  long,  which  ran  in  an  oblique 
direction  from  above  downward,  and  somewhat  anteriorly,  into 
the  cavity  of  the  tympanum,  so  that  the  bristle  passed  immedi- 
ately beneath  the  handle  of  the  malleus,  and  just  as  closely 
beneath  the  chorda  tympani.  On  pushing  the  bristle  still  farther, 
it  passed  under  the  tendon  of  the  inner  muscle  of  the  malleus, 
and  struck  on  the  inner  wall  of  the  cavity  of  the  tympanum." 

Dr.  Bochdalek  also  found  the  foramen  in  the  opposite  mem- 
brane of  the  same  subject,  as  well  as  in  sixty -three  other  prep- 
arations of  the  membrana  tympani.  Forty  of  them  were  from 
fresh  subjects,  the  remainder  had  been  preserved  in  alcohol.  In 
two  cases  only  the  opening  was  not  found.  In  both  these  cases 
morbid  changes  (thickening  ?)  had  occurred  in  the  drum-head. 


'  Loc.  cit.  *  Loc.  cit. 

3  Anatomic  des  Menschen,  p.  520.  .  *  Prag  Viertel.  Jahrschrift,  January,  1866. 


218  RIVINIAN   FORAMEN. 

Kessel1  believes  that  the  foramen  is  the  result  of  inflamma- 
tion. He  says  that  he  has  convinced  himself  of  the  correctness 
of  this  view,  by  dissections  and  by  examination  of  the  living 
subject  at  Gruber's  clinic. 

I  believe  in  the  existence  of  the  foramen  of  Rivinus,  from  the 
clinical  fact  that  I  have  heard  a  whistling  sound,  seemingly 
through  the  membrana  tympani,  in  several  cases,  when  the  Val- 
salvian  experiment  was  made,  when  neither  myself  nor  other  ob- 
servers could  detect  the  slightest  opening  with  the  eye.  I  have 
also  been  startled,  in  one  or  two  instances,  on  blowing  my  nostrils 
violently,  by  hearing  the  air  whistle  through  the  drum-head,  as 
it  seemed.  On  one  occasion,  I  immediately  consulted  a  friend 
•who  has  large  experience  in  examining  the  membrana  tympani, 
and  he  decided  that  it  was  not  perforate,  as  did  several  others 
who  soon  examined  the  ear.  Indeed,  I  have  never  suffered  from 
any  disease  of  the  ear,  that  led  me  to  suppose  the  drum-head  could 
be  perforate. 

I  cannot  escape  the  subjective  conviction,  therefore,  that  the 
foramen  of  Rivinus  exists,  and  that  air  may  be  occasionally 
heard  to  whistle  through  it,  although  the  opening  itself  cannot 
be  seen. 

Mr.  Wharton  Jones2  described  the  circular  and  radiating  fibres 
of  the  membrana  tympani  in  his  article  on  the  organ  of  hearing. 

Sir  Everard  Home3  supposed  that  these  fibres  were  muscular,  and  he  thought 
that  by  this  muscle  ' '  accurate  perceptions  of  sounds  were  conveyed  to  the  inter- 
nal organ."  Mr.  Home  admitted  that  the  muscles  of  the  malleus  stretched  and 
relaxed  the  membrana  tympani,  but  only  in  order  to  bring  the  radiated  muscle 
into  a  state  capable  of  acting. 

Mr.  Home  reports  a  case  of  double  hearing,  and  he  explains  it  by  a  defective 
action  of  the  radiated  muscle,  which  was  not  exerted  with  the  same  quickness 
and  force  in  one  ear  as  in  the  other,  so  that  the  sound  was  half  a  note  too  low, 
as  well  as  later  in  being  impressed  upon  the  organ.  It  is  interesting  to  note  that 
nearly  all  the  cases  of  double  hearing  are  observed  as  occurring  in  musicians. 

The  patient,  judging  from  the  history,  evidently  had  a  catarrh  of  the  tym- 
panic cavity,  and  the  double  hearing  probably  arose  from  unequal  pressure  on 
the  labyrinths. 

The  objects  in  the  membrana  tympani,  which  first  strike  the 
attention  of  the  observer,  are  the  handle,  or  long  process  of  the 
malleus  bone,  and  the  triangular  spot  of  light.  I  am  now  speak- 
ing of  the  membrane,  when  viewed  through  the  auditory  canal. 
When  this  is  detached,  the  reflection  called  the  light  spot,  is  not 

1  Strieker's  Hand-book  of  Histology,  p.  953. 

*  Cyclopaedia  of  Anatomy  and  Physiology,  vol.  ii. 

3  Philosophical  Transactions  of  the  Royal  Society  of  London,  1800.     Part  I. 


LIGHT   SPOT.  219 

seen,  because  one  of  the  conditions  for  its  formation  is  removed, 
as  is  also  true,  to  a  certain  extent,  of  a  membrane  seen  after 
death,  when  the  tissues  are  macerated. 

The  long  process  of  the  malleus,  also  called  the  handle  or 
manubrium  of  the  malleus,  divides  the  membrane  into  two  parts. 
The  anterior  part  is  smaller  than  the  posterior.  The  attachment 
of  the  malleus  between  the  layers  of  the  drum-head  will  be 
described  in  the  description  of  these  parts. 

At  the  extremity  of  the  handle  of  the  malleus  is  situated  the 
apex  of  the  light  spot.  This  point  is  also  the  place  of  greatest 
concavity  of  the  outer  surface  of  the  drum-head,  and  is  called 
the  umbo  (boss  of  a  shield),  or  navel  of  the  membrane. 

The  light  spot,  as  will  be  seen  in  the  chapter  on  chronic  non- 
suppurative  disease  of  the  middle  ear,  is  one  of  the  important 
standpoints  for  the  diagnosis  of  certain  affections  of  the  middle 
ear.  The  study  of  the  conditions  necessary  to  its  formation  is 
therefore  of  importance. 


FIGS.  55,  56. — View  of  Membrana  Tyrapani,  showing  Handle  of  Malleus  and  Triangular  Spot 

of  Light. 

An  account  of  the  normal  color  of  the  membrana  tympani 
will  be  found  in  the  chapter  on  chronic  non-suppurative  in- 
flammation. Until  the  investigations  of  Troltsch  and  Politzer, 
this  was  described  as  seen  in  the  dead  subject ;  but  the  post- 
mortem appearances  of  this  membrane,  are  no  guide  to  its  ap- 
pearance in  the  living  subject.  The  ordinary  breadth  of  the 
light  spot,  at  its  base,  is  from  one  and  a  half  to  two  millimetres. 
— (Politzer.)  It  is  sometimes  interrupted  in  its  continuity. 

The  chief  causes  of  the  existence  of  the  light  spot,  according 
to  Politzer,1  are  the  inclination  of  the  membrane  to  the. axis  of 
the  external  auditory  canal,  and  the  concavity  produced  by  the 
traction  of  the  handle  of  the  malleus. 

If  light  be  thrown  upon  a  dried  preparation  of  the  human  ear, 
as  in  the  examination  of  the  living  subject,  through  the  auditory 
canal,  the  light  spot  will  be  found  in  the  same  position  as  it  is 
seen  in  life.  It  is  also  displaced  very  little  by  moving  the  eye  in 

1  The  Membrana  Tympani,  p.  26.     Mathewsou  and  Newton's  translation. 


220  LIGHT   SPOT. 

different  directions,  because  the  axis  of  vision  corresponds  so 
nearly  to  the  axis  of  the  meatus,  that  the  light  spot  can  change 
very  little  with  respect  to  the  inclination  to  the  membrana  tym- 
pani. 

No  light  would  be  reflected  to  the  eye,  if  the  membrane  were  a 
plane  surface ;  for,  with  its  inclination  to  the  auditory  canal,  all 
rays  thrown  upon  it  would  be  reflected  against  the  anterior  and 
lower  wall  of  the  canal.  In  consequence,  however,  of  the  inward 
curvature  from  the  traction  of  the  handle  of  the  malleus,  its  parts 
undergo  such  a  change  of  inclination  that  the  anterior  portion 
stands  directly  at  right  angles  to  the  axis  of  vision  of  the  ob- 
server, and  the  light  thrown  upon  it  is  reflected  back  to  the  eye. 

Politzer  proved  the  correctness  of  this  opinion  by  stretching 
an  animal  membrane  over  a  large  ring,  and  giving  it  the  inclina- 
tion of  the  membrana  tympani.  No  reflection  will  be  perceived 
until  the  central  portion  is  pressed  inward,  or  made  concave  by 
traction  from  behind  it. 

Helmholtz  '  also  states  that  the  triangular  spot  of  light  is  due 
to  reflection.  Voltolini a  claims  that  the  light  spot  may  be  seen 
when  no  auditory  canal  is  present ;  indeed,  even  when  the  mem- 
brane is  completely  removed.  This  seems  to  me  to  be  a  mistake ; 
for  while  there  is  a  reflex  from  any  generally  convex  brilliant 
membrane,  such  as  the  drum-head,  although  it  has  a  central  con- 
cavity, there  is  no  such  triangular  and  fixed  one,  as  when  the 
auditory  canal  is  present,  and  this  is  the  whole  point  of  the  theory 
of  Politzer. 

Voltolini  is  Correct,  however,  in  calling  attention  to  other 
modifications  of  the  light  spot,  than  its  inclination  in  the  audi- 
tory canal.  If  this  part  of  the  membrane  become  thickened,  in- 
flamed, or  infiltrated ;  in  other  words,  if  from  mechanical  or 
chemical  causes  it  cease  to  be  a  brilliant  membrane,  and  it  does 
not  reflect  light  as  well  as  formerly,  the  light  spot  will  no  longer 
be  triangular  in  shape,  and  perhaps  not  exist  at  all ;  but  neither 
the  concavity  nor  polish  of  the  membrane  have  all  to  do  with  the 
existence  of  the  light  spot,  as  Voltolini  asserts.  Any  person  can 
prove  this  for  himself  by  a  few  simple  experiments,  with  a  mem- 
brane stretched  over  the  end  of  a  tube. 

The  -light  spot  depends  upon  three  factors,  viz.  : 
I.  The  inclination  of  the  membrana  tympani  to  the  audi- 
tory canal. 

II.  The  traction  of  the  malleus,  which  renders  it  concave  at 
the  centre. 

III.  Its  polish  or  brilliancy. 

1  Monatsschrift  fur  Olirenheilkunde,  Jahrgang  VI.,  No.  8.  2  Loc.  cit. 


LAYEKS  OF  MEMBRANA  TYMPANI. 


221 


THE  LAYERS  OF  THE  MEMBRANA  TYMPANI. 

The  membrana  tympani  is  not  quite  0.1  mm.  in  thickness 
(Henle)  —  about  as  thick  as  very  fine  letter-paper  or  gold-beaters' 
skin.  This  thickness  varies  within  small  limits. 

There  are  three  layers  in  the  structure  of  the  membrana  tym- 
pani. 

1.  A  thin  layer  of  integument. 

2.  A  fibrous  layer.     This  layer  forms  the  principal  thickness 
of  the  membrane. 

3.  A  mucous  layer  continuous  with  that  of  the  tympanic 
cavity. 

The  integumentary  layer  may  be  easily  separated  from  the 
fibrous  layer,  but  the  mucous  membrane  is  so 
closely  connected  to  it  that  it  is  impossible  to 
separate  them.  —  (Politzer.) 

It  is  made  up  of  many  layers  of  pavement 
epithelium  with  a  Malpighian  mucous  layer.  It 
has,  however,  a  very  thin  layer  of  connective 
tissue,  which  is  arranged  differently  from  the 
fibre  of  the  lamina  propria,  and  in  which  a  con- 
stant relation  to  the  vessels  and  nerves  of  the 
outer  layer  is  observed.  —  (Politzer.) 

The  first  or  integumentary  layer  of  the  mem- 
brana tympani  has  none  of  the  hairs  or  glands 
of  the  lining  of  the  canal,  of  which  it  is  a  direct 
continuation.  The  papillae  are  found  as  far  as 
the  short  process  of  the  malleus. 

The  epidermal  cells,  the  cuticle,  and  corium 
diminish  gradually  in  thickness  from  the  per-  Section 
iphery  toward  the  handle  of  the  malleus;  they 
then  increase  and  are  thickest  on  the  outer  edge  Henle).   i  x  soo. 
of  this  bone. 

The  fibrous  layer  consists  of  lamellae,  each  one  of  which  forms 
a  mesh-work  of  smooth  fibres  with  narrow,  almost  fissure-shaped 
apertures.  The  fibres  have  an  average  breadth  of  0.01  mm. 

The  majority  of  the  fibres  run  to  the  malleus  in  a  radiating  or 
circular  direction.  A  small  number  of  them,  however,  run  in 
different  directions  between  these  two  sets  of  fibres.  The  radiat- 
ing fibres  are  external,  beneath  the  cutis,  the  circular  next  to  the 
mucous  membrane. 

The  fibres  of  the  membrana  tympani  are  sharply  outlined 
and  opaque,  flattened  on  the  sides,  swelling  out  in  the  middle. 
They  are  from  0.0036  mm.  to  0.0108  mm.  in  thickness.  Some- 


FIG.  57.—  Vertical 
of    Fibrous 


222  LAYERS    OF   MEMBRANA   TYMPANI. 

times  they  appear  to  be  homogeneous,  but  they  are  actually 
fibrillated.  Chromic  acid,  chloride  of  gold,  and  osmic  acid 
bring  out  the  fibrillated  structure. — (Kessel.) 

The  fibrous  layer  might  be  well  described,  according  to  Kes- 
sel, "as  a  deep  layer  of  the  corium  changed  and  adapted  for 
physiological  purposes.''  The  slits  or  apertures  which  have 
been  spoken  of  are  usually  empty  and  appear  to  glisten,  or  on 
their  edges  they  are  covered  by  a  finely  granular  mass. 

Cells  are  sometimes  found  which  fill  them  exactly.  Troltsch 
called  these  cells  the  corpuscles  of  the  membrana  tympani,  and 
they  are  named  Troltsch's  cells.  The  larger  spaces  contain  en- 
capsulated nuclei,  and  are  frequently  filled  with  amaeboid  cells. 

On  the  periphery  the  thin  layers  of  the  membrana  tympani 
interweave,  leaving  large  and  small  spaces  between  the  fibres 
for  the  passage  of  vessels,  and  form,  by  union  with  the  outer 
and  internal  layers,  the  "tendinous  ring,"  which  is  attached  by 
means  of  a  thin  periosteum  to  the  osseous  ring,  or  annulus  tyni- 
panicus. 

All  the  layers  of  the  fibrous  portion  are  united  to  the  osseous 
ring.  Kessel  confirms  Grubers  observation  that  the  circular 
fibres  may  be  followed  into  the  tendinous  ring ;  but  he  adds, 
"these  fibres  singly,  and  at  some  distance  from  each  other, 
pass  off  again  from  the  ring  at  very  acute  angles,  collect  to- 
gether, and  reach  nearly  as  great  thickness  as  that  which  results 
from  the  union  of  the  fibres,  coming  from  the  epidermis,  cutis. 
and  mucous  membrane.''  The  tension  of  these  fibres  causes  a 
convexity  of  the  radii  of  its  surface  toward  the  meatus  externus, 
giving  the  membrane  a  general  convexity.  The  circular  fibres 
do  not  exist  on  the  lower  third  of  the  handle  of  the  malleus  and 
the  adjacent  parts. 

The  organic  muscular  fibres  described  by  Sir  Everard  Home 
have  been  rediscovered  by  Prussak,  as  spindle-shaped  fibres  in 
the  membrane. 

The  handle  of  the  malleus  is  attached  to  the  fibrous  layer  be- 
tween the  radiating  and  circular  fibres.  According  to  Gruber, 
there  is  a  cartilaginous  formation,  which  begins  over  the  short 
process  of  the  malleus,  and  extends  £  mm.  below  the  handle. 
This  is  firmly  united  below ;  but  above,  at  the  short  process, 
there  is  a  kind  of  a  joint,  the  cavity  of  which  is  filled  with  syno- 
vial  fluid. 

Prussak,  Moos,  and  Kessel '  say  that  while  this  cartilage  ex- 
ists— that  is  to  say,  that  a  third  of  the  short  process  is  of  car- 
tilage— it  passes  into  the  osseous  portion  without  interruption. 

1  Strieker's  Hand-book,  p.  955. 


LAYERS   OF   MEMBRANA   TYMPANI.  223 

There  is  also,  according  to  Prussak  and  Moos,  a  thin  layer  of 
cartilage  cells  under  the  periosteum  of  the  handle  of  the  malleus 
not  only  in  infants,  but  also  in  adults. 

Kessel  found  on  sections  of  the  ossicles  in  embryos  from 
three  to  nine  months,  that  the  malleus  is  surrounded  by  an  in- 
dependent periosteum  distinct  from  the  elements  of  the  fibrous 
layer,  and  only  united  with  the  mucous  layer  by  a  duplicature 
of  the  mucous  membrane.  In  place  of  the  short  process  there 
are  a  great  number  of  glistening  nucleated  cells  under  the  peri- 
osteum and  in  the  duplicature  of  tissue.  These  elements  remain 
through  life  as  cartilage  cells,  and  form  a  solid  mass  with  the 
osseous  portion  of  the  small  process. 

At  birth,  the  malleus  is  only  closely  united  to  the  membrana 
tympani  at  two  points — at  the  short  process,  and  at  the  lower 
third  of  the  handle.  The  fibrous  layer  is  united  with  the  perios- 
teum of  the  upper  portion  of  the  handle  of  the  malleus  only  by 
loose  connective  tissue,  so  that  a  slight  motion  of  the  bone  is 
possible  at  this  point,  without  an  articulation. 

The  mucous  layer  consists  of  an  epithelium  and  a  fibrous 
framework  beneath  it.  On  the  inner  side  of  the  membrane,  at 
the  upper  part  of  its  posterior  half,  is  found  an  irregularly  tri- 
angular fold,  3  mm.  to  4  mm.  high  and  4  mm.  broad,  which 
arises  close  behind  the  annulus  tympanicus,  and  extends  to  the 
handle  of  the  malleus.  A  cavity  is  thus  formed  which  opens 
below,  which  is  called  by  Troltsch,1  who  described  it,  "the  pos- 
terior pouch  "  of  the  membrana  tympani. 

The  best  view  of  this  duplicature  is  seen  by  viewing  the 
membrana  tympani  from  the  inside,  while  it  is  still  in  position, 
after  the  roof  of  the  tympanic  cavity  has  been  removed,  and 
the  incus  detached  from  the  malleus ;  but  it  may  even  be  seen 
from  the  outer  surface,  by  a  good  illumination,  in  the  living 
subject.  The  tissue  of  the  pocket  is  the  same  as  that  of  the 
fibrous  layer. — (Troltsch.) 

A  similar  space  is  found  in  front  of  the  malleus,  but  this  is 
not  formed  by  a  duplicature  of  the  fibrous  layer,  but  by  a  small 
long  process  turned  toward  the  neck  of  the  malleus,  by  the  mu- 
cous membrane  that  lines  the  tympanic  cavity,  and  by  all  the 
parts  that  enter  and  leave  the  Glaserian  fissure,  that  is  to  say 
by  the  long  process  of  the  malleus,  by  its  anterior  ligament,  the 
chorda  tympani  nerve,  and  the  inferior  tympanic  artery. 

Villous  processes  are  found  on  the  edge  of  the  mucous  mem- 
brane, especially  in  children.  These  processes  are  also  found 


1  Von  Troltsch :  Lehrbnch  der  Ohrenlieilkunde,  Vierte  Aufgabe,  p.  38.     1868. 


224  BLOOD- VESSELS   OF   MEMBRANA   TYMPANI. 

on  the  pouch  of  Troltsch  and  on  the  malleus.  They  are  covered 
by  flattened  epithelium,  and  are  composed  of  connective  tissue 
in  which  there  are  capillary  loops. 


BLOOD-VESSELS. 

According  to  the  investigations  of  Kessel,  there  are  blood- 
vessels, nerves,  and  lymphatics  in  all  the  layers  of  the  meni- 
brana  tympaiii.  It  had  been  previously  taught  by  nearly  all 
the  writers,  that  there  were  no  blood-vessels  or  nerves  in  the 
fibrous  layer  of  the  drum-head,  although,  according  to  Gerlach, 
there  was  a  capillary  anastomosis  between  the  mucous  mem- 
brane and  the  cutis  on  the  periphery  of  the  middle  or  fibrous 
layer.  Kessel '  also  claims  to  have  first  described  the  lymph- 
vessels. 

According  to  Kessel,  there  is  a  direct  passage  of  blood-vessels 
from  the  outer  layer  of  the  membrana  tympani  to  the  cavity  of 
the  tympanum ;  a  complete  capillary  network  in  the  fibrous 
layer  communicates  with  the  cutis  and  the  mucous  membrane. 

The  blood-vessels  that  pass  from  the  auditory  canal  down 
upon  the  membrana  tympani,  come  from  the  deep  auricular 
artery,  which  is  a  branch  of  the  internal  maxillary. 

Those  on  the  mucous  membrane  arise  from  the  vessels  of  the 
tympanic  cavity. 

The  blood-supply  of  the  outer  layer  of  the  membrane  may  be 
very  readily  traced  in  many  cases  of  inflammation,  or  after  in- 
jecting the  canal  with  warm  water.  The  whole  circumference 
of  the  membrane  is  usually  found  injected  in  connection  with 
redness  of  the  lower  part  of  the  canal.  Larger  vessels  run  im- 
mediately behind  the  handle  of  the  malleus  to  the  uinbo,  where 
they  pass  off  in  radii  to  the  edge. 

NERVES  OF  THE  MEMBRANA  TYMPANI. 

Nerves  are  found  in  each  layer  of  the  membrana  tympani. 
The  larger  nerve-trunks  accompany  the  chief  vessels.  They 
divide  as  these  do,  and  frequently  unite  together  like  the  capil- 
laries. They  form  thick  networks  under  the  epithelium  of  the 
cutis,  and  also  under  that  of  the  mucous  membrane.  A  funda- 
mental plexus,  a  capillary  plexus  near  the  vessels,  and  a  sub- 
epithelial  plexus  may  be  distinguished. 

The  chief  nerve-trunk  consists  of  medullated  fibres,  which  is 
provided  with  a  sheath  of  Schwann,  and  lies  on  the  boundary 

1  Loc.  cit.,  p.  958. 


NERVES    OF   MEMBRANA   TYMPANI. 


225 


between  the  cutis  and  the  fibrous  layer.  It  passes  on  to  the 
membrane  at  the  upper  part  of  the  posterior  segment.  Besides 
this  chief  trunk,  several  small  branches  enter  the  membrane  at 
different  parts  of  the  periphery. 

In  addition  to  the  openings  in  the  fibrous  layers,  with  their 
contents,  Kessel  found  a  large  number  of  nucleated  swellings, 
provided  with  two  or  more  processes,  that  unite  with  the  nerve- 
fibres,  and  which  lie  above  and  between  the  single  fibrous  layers. 


FIG.  58. — The  Membrana  Tympani,  in  connection  with  the  Ossicula  Auditus  of  the  Right 
Temporal  Bone  (from  a  photograph — Riidinger).  1,  Transverse  section  of  the  fossa  sig- 
moidea,  in  which  is  the  transverse  sinus ;  2,  lower  section  of  the  transverse  sinus ;  3,  inner 
side  of  the  transverse  wall  thrown  back,  which  causes,  4,  the  emissarius  mastoideus  to  be 
opened ;  5,  carotid  canal ;  6,  the  membrana  tympani  connected  to  the  mucous  membrane  of 
the  cavity  of  the  tympanum  ;  7,  the  malleus  on  the  anterior  and  upper  portion  of  the  handle 
(the  pockets  of  the  membrana  tympani  are  seen) ;  8,  the  divided  tendon  of  the  tensor  tympani 
muscle ;  9,  the  incus ;  10,  stapes  lying  by  the  stapedius  muscle,  on  the  pyramid,  which  is 
opened ;  11,  stapedius  muscle  ;  12,  section  of  facial  nerve  ;  13,  chorda  tympani  nerve. 

The  greater  part  of  the  cell  elements  found  between  the 
fibres  of  the  fibrous  layer,  must  be  considered,  according  to 
Kessel,  as  belonging  to  the  blood-  and  lymph-vessels,  and  to  the 
nervous  system.1 


15 


Kessel,  in  Strieker's  Hand-book,  p.  962. 


NERVES  OF  MEMBRANA  TYMPANI. 

The  nerves  of  the  mucous  membrane  of  the  membrana  tym- 
pani  are  also  more  numerous,  according  to  the  author  from 
whom  I  have  just  quoted,  than  has  been  hitherto  supposed. 
There  is  a  plexus  near  the  vessels,  and  a  sub,-epithelial  plexus. 
The  former  accompanies  the  lymph-  rather  than  the  blood-vessels. 
Its  receives  its  fibres,  in  part,  from  threads  of  the  tympanic 
plexus,  which  pass  on  to  the  membrane,  with  the  mucous  mem- 
brane, from  different  parts  of  the  periphery,  and  partly  from  the 
nerves  of  the  cutis,  passing  through  the  fibrous  layer.  The  sub- 
epithelial  plexus  is  a  fine  network  directly  under  the  epithelium, 
which  it  supplies  with  threads.1 

The  outer  nerve-supply  of  the  membrana  tympani  is  from  the 


Pio.  59. — Left  Temporal  Bone  (two-thirds  of  the  normal  size).  1,  Squamous  portion  of 
temporal  bone  ;  2,  petrous  portion  of  temporal  bone  ;  3,  mastoid  portion  of  temporal  bone ; 
4,  internal  auditory  canal ;  5,  depression  from  dura  mater  ?  6,  sup.  petrosal  sinus  ?  7,  eminence 
from  semicircular  canal ;  8,  carotid  foramen  ;  9,  zygomatic  process  ;  10,  groove  for  meningeal 
artery  ;  11,  mastoid  foramen  ;  12,  lateral  sinus. 

fifth  pair.     The  main  trunk  is  a  branch  of  the  superficial  tem- 
poral nerve,  from  the  third  branch  of  the  trifacial  or  fifth  nerve. 
The  chorda  tympani  nerve  runs  along  the  inner  surface  of  the 
membrana  tympani,  but  gives  no  branches  to  it. 


LYMPH-VESSELS. 

They  are  arranged  in  three  layers,  like  those  of  the  blood- 
vessels. The  first  layer  belongs  to  the  cutis,  the  second  to  the 
fibrous  layer,  and  the  third  to  the  mucous  membrane.  In  the 
cutis  they  form  a  very  fine  network,  immediately  under  the  rete 
Malpighii.  This  network  passes  over  the  capillaries  at  many 
points.  They  gradually  pass  into  large  capillaries,  which  often 

1  Kessel,  p.  963. 


THE  TYMPANUM. 


227 


interlace  with  the  blood  capillaries,  and  finally  unite  in  indepen- 
dent and  larger  trunks.  These  run  either  posteriorly  and  above, 
or,  exactly  like  the  blood-vessels,  pass  at  various  points  to  the 
periphery  and  to  the  auditory  canal. 

In  the  mucous  membrane,  also,  there  is,  although  not  in  large 
number,  a  sub-epithelial  network,  lying  near  the  tendinous  ring. 
These  vessels  are  distinguished  from  the  blood  capillaries  of  the 
same  width  by  their  manifold  dilatations.1 

THE  CAVITY  OF  THE  TYMPANUM. 

The  tympanum  (drum),  cavity  of  the  tympanum,  or  drum  of 
the  ear,  is  the  irregular,  air-containing  space  lying  beyond  the 
membrana.tympani.  The  mastoid  cells,  also  containing  air,  and 
lying  in  the  mastoid  portion  of  the  temporal  bone,  are  connected 
with  the  tympanum  at  its  upper  and  posterior  part;  while  the 
Eustachian  tube  permits  the  entrance  of  air  into  the  cavity 
through  the  upper  part  of  its  anterior  wall. 

The  points  to  be  noted  in  the  description  of  the  tympanic 
cavity  are  indicated  in  the  following  scheme  : 


THE 

TYMPANUM 

presents  for  ex-  " 
animation  its 


1.  DIMENSIONS. 


2.  WALLS. 


3.  OSSICLES. 


4.  LIGAMENTS. 


5.  MUSCLES. 


the  Anterior, 
the  Posterior, 
the  Outer, 
the  Inner, 
the  Upper, 
the  Lower. 

Malleus. 

Incus. 

Stapes. 

Ligaments  of  mov- 
able joints. 


Ligaments   of    im- 
movable joints. 


Tensor  Tympani. 
Stapedius. 


Malleus — Incus. 
Incus —  Tympanum. 
Incus — Stapes. 

Obturator  Stapedis. 
Mallei  Superior. 
Mallei  Anterior. 
Incudis  Superior, 


6.  Mucous  MEMBRANE. 

7.  VESSELS. 

8.  NEBVES. 


1  Kessel:  Handbuch  der  Lehre  von  den  Geweben,  p.  851. 


228  DIMENSIONS    OF   THE   TYMPANUM. 

1.  The  dimensions  of  the  tympanum,  like  those  of  the  exter- 
nal auditory  meatus,  vary  much  in  different  individuals.     The 
following  table  shows  about  the  average  diameters  as  given  by 
Troltsch  : ' 

Antero -posterior  diameter, 13  mm. 

Vertical  "  .  .at  anterior  part,  .  .  5  to  8  mm. 

"  "  .  at  posterior  "  .  .15  mm. 

Transverse  "  .  .at  anterior  "  .  .  3  to  4.5  mm. 

"  "  .  opposite  the  drum-head,  2  mm. 

2.  The  anterior  ivall  presents,  at  its  upper  part,  an  opening  of 
considerable  size — the  tympanic  orifice  of  the  Eustachian  tube. 
Below  this  is  a  strong  bony  plate. 

The  measurements  of  a  cast  of  the  tympanic  cavity  repre- 
sented on  page  93,  are  as  follows  : 

Distance  from  attachment  of  upper  part  of  the  membrana 
tympani  to  the  superior  margin  of  the  opening  of  the  Eustachian 
tube,  1£  line  ;  from  opening  of  mastoid  cells  above  to  the  supe- 
rior margin  of  the  opening  of  Eustachian  tube,  3£  lines ;  from 
opening  of  mastoid  cells  below  to  the  inferior  margin  of  the 
opening  of  the  Eustachian  tube,  6£  lines ;  vertical  diameter  of 
the  tympanic  cavity,  6  lines ;  distance  from  the  membrana  tym- 
pani to  upper  inner  wall,  2  lines ;  to  lower  inner  wall,  1  line  ; 
opening  of  Eustachian  tube,  vertical  diameter,  1£  line  ;  horizon- 
tal diameter,  1  line.  A  plaster  of  Paris  cast  contracts  somewhat, 
so  that  these  measurements  are  actually  too  small. 

The  posterior  wall  separates  the  cavity  of  the  tympanum 
from  the  mastoid  cells.  The  opening  into  the  cells  is  at  its 
upper  part,  close  under  the  roof,  and  considerably  higher  than 
the  orifice  of  the  Eustachian  tube. 

The  outer  wall  of  the  tympanic  cavity  is  composed,  for  the 
most  part,  of  the  membrana  tympani ;  but  it  extends  much 
further  backward  than  the  membrane,  and  contains  three  small 
openings  :  the  aperture  of  the  iter  chordae  posterius,  the  Glaser- 
ian  fissure,  and  the  aperture  of  the  iter  chordae  anterius. 

The  opening  of  the  iter  chordce  posterius  is  on  a  level  with 
the  centre  of  the  membrana  tympani  and  close  to  its  margin, 
and  gives  entrance  to  the  chorda  tympani  nerve.  The  nerve 
then  runs  upward  under  the  long  process  of  the  incus,  on  the 
free  margin  of  the  posterior  pocket  of  the  membrane,  then  for- 
ward across  the  neck  of  the  malleus,  and  finally  enters  the  iter 
chordce  anterius.  or  canal  of  Huguier.  The  Glaserian  fissure 

1  Text-book,  translation,  p.  171. 


FENESTRA   OVALIS   AND   FENESTRA   ROTUNDA.  229 

opens  above,  and  in  front  of,  the  membrana  tympani ;  while 
just  above  it  is  seen  the  aperture  of  the  Her  chordae  anterius. 

The  inner  wall  of  the  tympanum  is  the  outer  boundary  of 
the  labyrinth,  and  consists  of  bone.  It  has  two  small  apertures 
closed  by  membranes.  The  upper  and  larger  opening  is  called 
the  fenestra  ovalis,  or  oval  window,  and  leads  into  the  vesti- 
bule ;  while  the  lower  and  smaller  one  is  called  the  fenestra 


FIG.  60. — The  Right  Temporal  Bone,  with  the  Membrana  Tympani  and  Ossicula  Auditus  of 
•an  Adult.  1,  Squamous  portion — under  figure  1  the  sulcus  of  the  transverse  sinus  runs  down- 
ward ;  2,  a  bristle  passes  through  the  mastoid  foramen  ;  3,  mastoid  cells ;  4,  antrum  of  the 
mastoid,  communicating  both  with  the  mastoid  cells  and  with  the  tympanic  cavity ;  5,  styloid 
process  ;  6,  membrana  tympani — a  point  of  mucous  membrane  of  the  tympanic  cavity  is  seen 
under  the  number  6 ;  7,  the  malleus — under  the  chorda  tympani  we  see  the  divided  tendon  of 
the  tensor  tympani  muscle;  8,  the  incus;  9,  the  short  process  ;  10,  the  chorda  tympani  nerve; 
11,  the  stapes ;  12,  stapedius  muscle ;  13,  facial  nerve ;  14,  stapedius  nerve,  branch  of  facial. 
The  relations  of  the  mastoid  cells  to  the  cavity  of  the  tympanum  and  the  relations  of  the 
former  to  the  transverse  sinus  are  well  shown.  (After  Rildinger.) 

rotunda,  or  round  window,  and  communicates  with  the  cochlea. 
The  former  is  closed  by  the  periosteum  of  the  vestibule,  to  which 
the  base  of  the  stapes  is  attached.  The  fenestra  rotunda  lies 
below  the  fenestra  ovalis,  and  is  closed  by  the  membrana  tym- 
pani secundaria.  Both  these  openings  may  perhaps  more  prop- 
erly be  called  canals,  since  they  have  considerable  depth,  the 
membranes  which  close  them  lying  at  their  inner  extremities. 


230  ANATOMY   OF  TYMPANUM. 

In  front  of  the  fenestrse,  and  partly  between  them,  lies  the 
promontory,  a  projection  of  the  first  whorl  of  the  cochlea. 
Upon  it  may  be  seen  three  shallow  grooves  for  branches  of  the 
tympanic  plexus.  In  front  of  the  promontory  the  inner  wall  of 
the  tympanum  consists  of  a  very  thin  plate  of  bone  separating 
this  cavity  from  the  carotid  artery.  This  plate  is  pierced  by 
many  minute  openings  for  vessels  and  nerves,  and  has,  besides, 
many  irregularities  on  its  tympanic  surface. 

Just  above  and  behind  the  f enestra  ovalis,  is  a  slight  rounded 
ridge,  corresponding  to  the  aquceductus  Fallopii,  which  gives 
passage  to  the  facial  nerve.  This  canal  is  covered  by  an  ex- 
tremely thin  plate  of  bone.  Behind  and  below  the  f  enestra 
ovalis  is  the  pyramid,  a  hollow,  bony  projection  containing  the 
stapedius  muscle.  The  bottom  of  this  cavity  of  the  pyramid  is 
in  communication  with  the  aquseductus  Fallopii,  by  means  of  a 


FIG.  61. — Section  of  Right  Temporal  Bone  (actual  size.  From  Professor  Darling's  mu- 
seum). 1,  Cochlea ;  2,  external  auditory  canal ;  3,  attachment  of  membrana  tympani  to  bony 
ring ;  4,  head  of  malleus  ;  5,  tympanic  cavity  ;  6,  mastoid  cells. 

minute  canal.  Just  behind  the  ridge  of  the  Fallopian  canal,  and 
about  on  a  level  with  the  fenestra  ovalis,  is  seen  a  hard,  smooth, 
bony  surface,  which  corresponds  to  the  external  or  horizontal 
semicircular  canal  of  the  labyrinth. 

The  upper  wall,  or  roof  of  the  tympanum,  is  the  partition  be- 
tween this  cavity  and  that  of  the  cranium.  Its  thickness  and 
density  vary  considerably  in  different  subjects.  It  is  sometimes 
very  thin  and  porous,  or  entirely  wanting,  so  that  the  tym- 
panum forms  a  part  of  the  cranial  cavity. 

The  lower  wall,  or  floor  of  the  tympanum,  separates  this 
cavity  from  the  jugular  vein.  Like  the  roof,  it  varies  greatly 
in  thickness,  being  sometimes  wholly  membranous.  It  is  very 
irregular  on  its  upper  or  tympanic  surface  ;  and  lying  much  be- 
low some  points  in  the  floor  of  the  external  auditory  meatus, 
and  below  the  orifices  of  the  Eustachian  tube  and  mastoid  cells> 


PATHOLOGICAL   CONDITIONS   OF  TYMPANUM.  231 

it  is  usually  covered,  in  cases  of  purulent  affections'  of  the 
middle  ear,  by  a  large  quantity  of  pus.  It  is  perforated  by  the 
glosso-pharyngeal  nerve  and  a  minute  vessel. 

Studied  with  an  eye  to  pathological  conditions,  some  of  these 
walls  present  very  important  relations.  Thus  the  roof  of  the 
tympanum  lies  in  contact  with  the  meninges  of  the  brain,  so 
that  in  caries  of  this  wall  the  patient  may  die  of  purulent  men- 
ingitis or  cerebritis.  Again,  caries  of  the  lower  wall  may  be 
followed  by  phlebitis  of  the  jugular  vein  ;  while  caries  of  the 


PIG.  62. — Section  through  Tympanic  Cavity,  Left  Temporal  Bone  (posterior  half,  actual 
aize.  From  Professor  Darling's  museum).  1,  Squamous  portion  of  temporal  bone  ;  2,  mastoid 
cells ;  3,  jugular  fossa ;  4,  canal  for  Jacobson's  nerve  ;  5,  carotid  foramen ;  6,  aquasductus 
Fallopii  ;  7,  fenestra  ovalis  ;  8,  fenestra  rotunda  ;  9,  promontory  ;  10,  Eustachian  tube. 

inner  wall  has  sometimes  caused  destruction  of  the  coats  of  the 
carotid  artery  and  fatal  hemorrhage,  also  a  suppurative  inflam- 
mation of  the  labyrinth,  with  extension  into  the  cavity  of  the 
skull.  It  is  easy  to  see,  too,  how  even  a  non-suppurative  in- 
flammation of  the  tympanum  may  affect  the  facial  nerve,  since, 
during  a  part  of  its  course,  the  nerve  is  separated  from  the  mu- 
cous membrane  only  by  a  thin  plate  of  bone,  which  may  even 
be  deficient  in  many  places.  Indeed,  swelling  of  this  nerve, 
causing  temporal  facial  paralysis,  or  destruction  of  it,  producing 
permanent  paralysis,  is  not  uncommon  in  connection  with  a 
suppuration  in  the  middle  ear. 


232  OSSICULA   AUDITTTS. 


OSSICTJLA  AUDITUS. 

3.  The  three  small  bones  of  the  ear,  the  ossicula  auditus, 
which  serve  for  the  conduction  of  the  sonorous  undulations 
through  the  tympanum  to  the  labyrinth,  are  the  malleus,  or 
hammer  ;  the  incus,  or  anvil ;  and  the  stapes,  or  stirrup. 

The  ossicles  are  articulated  to  each  other,  and  extend,  al- 
though not  in  a  straight  line,  from  the  membrana  tympani  to 
the  fenestra  ovalis. 

The  malleus  may  be  described  as  consisting  of  the  head, 
neck,  short  process,  manubrium  or  handle,  and  the  long  process 
or  processus  gracilis. '  The  head  is  the  larger,  upper  extremity 
of  the  bone.  Posteriorly  it  has  an  elliptical  depression,  twice  or 
thrice  as  long  as  it  is  broad,  and  of  considerable  depth  for  artic- 
ulation .  with  the  incus.  Below  the  head  is  a  constricted  por- 
tion called  the  neck,  and  just  below  this,  and  on  the  upper  end 


PIG.  63.— Tympanic  Cavity,  with  Ossi-  FIG.  64.— Anterior   Surface  of  Malleus 

cles  in  situ  (actual  size.    Prom  Professor  and  Incus.    Articulated  (twice  size.     From 

Darling's  museum).     1,  Fenestra  rotunda ;  Professor    Darling's    museum).      1,    Short 

2,  promontory ;  3,  annulus  tympanicus  ;  4,  process  of  malleus  ;  2,  head  of  malleus ;  3, 

incus ;  5,  handle  of  malleus  ;  6,  stapes ;  7,  handle    of   malleus  ;    4,    broken    processus 

head  of  malleus.  gracilis  ;  5,  long  process  of  incus ;  6,  short 

process  of  incus  ;  7,  body  of  incus. 

of  the  manubrium,  is  a  prominence  to  which  the  processes  are 
attached.  The  manubrium  extends  downward  and  inward,  be- 
ing inserted  into  the  drum-membrane  between  the  circular  and 
radiating  fibres  of  the  middle  layer.  The  processus  gracilis 
passes  from  the  eminence  below  the  neck  forward  and  outward 
to  the  Glaserian  fissure.  The  short  process  lies  at  the  base  of 
the  manubrium  opposite  where  it  gives  attachment  to  the  ten- 
sor tympani. 

The  incus  lies  just  back  of  the  malleus,  and  may  be  described 
as  having  a  body  and  two  processes.  On  the  anterior  and  inner 
surface  of  the  head  is  seen  the  surface  for  articulation  with  the 
malleus.  The  short  process  projects  backward  and  articulates 
with  the  posterior  wall  of  the  tympanum.  The  long  process, 

1  Some  writers  call  the  handle  of  the  malleus  the  long  process. 


OSSICULA   AUDITUS.  238 

much  more  slender  than  the  other,  descends  at  a  right  angle 
with  the  short  process,  and  parallel  with  and  behind  the  manu- 
brium,  to  end  in  the  processus  lenticularis,  which  articulates 
with  the  head  of  the  stapes.  This  articulation  lies  a  little  higher 
than  the  tip  of  the  manubrium. 

The  stapes  consists  of  the  head,  neck,  crura,  and  base,  and 
is  the  innermost  and  smallest  of  the  bones  of  the  ear,  and  in- 


Fio.  65.— Ossicles  of  the  Tympanum  (actual  size  and  twice  the  size.  From  Professor  Dar- 
ling's museum).  A,  Malleus.  1,  Short  process,  processus  brevis ;  2,  head ;  3,  processus  gra- 
cilis  ;  4,  handle,  manubrium.  B,  Incus.  1,  Body  ;  2,  short  process,  processus  brevis ;  3,  long 
process,  processus  longus.  C,  Stapes.  1,  Head ;  2,  base. 

deed  of  the  body.  The  head  presents  on  its  outer  part  a  surface 
for  articulation  with  the  lenticular  process  of  the  long  process 
of  the  incus.  Just  internally  to  the  head  is  the  constricted  por- 
tion called  the  neck,  into  which  is  inserted  the  stapedius  muscle. 
From  the  neck  the  crura  diverge  horizontally,  the  one  forward 
and  inward,  the  other  backward  and  inward,  to 
be  inserted  into  a  thin  plate  constituting  the 
base,  which  lies  upon  the  membrane  of  the  fen- 
estra  ovalis.  On  the  outer  side  of  the  base  is  a 
delicate  ridge  running  from  the  extremities  of 
the  crura  and  into  which  is  inserted  the  obtura- 

,.  Fio.  66. — Poste- 

tor  StapedlS.  rior  Surface  of  the 

The  dimensions  of  the  ossicles  are  :  length  of    Malleus,  incus,  and 
malleus  from  summit  of  head  to  short  process,    StaPes-  Articulated 

,  r  (twice    the    natural 

about  4£  mm. ;  from  short  process  to  the  end  of    size) 
the  handle,  4  to  5  mm.     Long  process  or  handle, 
about  2  mm.     Length  of  the  incus  from  summit  of  head  to  the 
end  of  the  long  process,  about  6J  to  7  mm.  ;  to  the  end  of  the 
short  process,  about  5  mm.    Length  of  the  stapes,  about  3  mm. 
Greatest  distance  between  the  crura,  about  2  mm.     Length  of 
the  base,  about  3  mm.  ;  width,  about  1  mm.     The  long  process, 
or  processus  gracilis,  is  sometimes  called  the  processus  Folianus 
(Coelius  Folius,  Venice,  1645),  and  also  the  process  of  Rau,  after 
Professor  Jacob  Rau,  of  Leyden. 

4.  Of  the  ligaments  of  the  ossicles  we  have  two  classes :  the 


234  LIGAMENTS   OF   OSSICULA   AUDITUS. 

ligaments  of  the  movable  joints  and  those  of  the  immovable 
joints. 

The  malleo-incus  joint  may  be  classed  with  the  gynglimus 
articulations  on  account  of  the  character  of  the  articulating  sur* 
faces.  These  surfaces  are  covered  by  cartilage  about  0.04  mm- 
in  thickness.  The  capsule  is  tense.  This  joint  is  provided  with 
synovial  membrane. 

.The  articulation  between  the  short  process  of  the  incus  and 
the  posterior  tympanic  wall  is  an  amphiarthrosis,  and  is  sur- 
rounded by  a  tolerably  thick  and  tense  capsule.  The  motion  is 
quite  restricted. 

The  joint  between  the  processus  lenticularis  of  the  incus  and 
the  head  of  the  stapes  is  an  arthrosis,  the  processus  lenticularis 
corresponding  to  the  ball  and  the  head  of  the  stapes  to  the  socket. 
Both  surfaces  are  covered  with  cartilage.  The  cartilage  is  much 
more  delicate  than  those  of  the  other  joints,  and  is  characterized 
by  being  rich  in  elastic  fibres. 

The  ligamentum  obturatorium  stapedis  is  a  thin  membrane 
inserted  into  the  ridge  on  the  outer  side  of  the  base  of  the  stapes 
and  into  the  inner  edges  of  the  crura,  closing  the  opening  formed 
by  these  parts. 

The  head  of  the  malleus  sometimes  lies  in  contact  with  the 
roof  of  the  tympanic  cavity.  More  frequently  it  is  connected 
with  the  roof  by  the  cylindrical  lig.  mallei  superius  (Soemmering). 
The  neck  of  the  malleus  is  held  in  place  by  the  cartilage  which 
sometimes  takes  the  place  of  the  long  process,  and  by  the  lig. 
mallei  anterius  (Arnold),  which  goes  from  the  spina  angularis 
of  the  sphenoid  parallel  with  the  fissura  petro-tympanica,  to  be 
inserted  upon  the  head  of  the  malleus. 

The  incus,  when  not  in  immediate  contact  with  the  roof  of 
the  tympanum,  is  attached  to  the  roof  by  means  of  the  lig.  in- 
cudis  superius  (Arnold),  and  is  inserted  into  the  posterior  border 
of  the  body  of  the  bone. 

The  posterior  surface  of  the  head  of  the  malleus  is  oblong, 
and  it  extends  in  spiral  form  from  above  downward  and  inward 
to  the  boundary  of  the  neck.  It  consists  of  two  surfaces,  which 
meet  in  an  almost  vertical  edge.  The  incus  has  an  articular  sur- 
face corresponding  to  this.  These  surfaces  are  covered  by  a  thin 
layer  of  hyaline  cartilage.  The  capsular  ligament  connecting 
the  bones  allows  of  considerable  motion.  A  fold,  described  by 
Pappenheim  (1840)  and  Riidinger,  projects  into  the  cavity  of  the 
joint. 

The  mechanism  of  the  joint  between  the  malleus  and  incus  is 
compared  by  Helmholtz  to  the  cog  contained  in  certain  watch- 
keys,  where  the  handle  cannot  be  turned  in  one  direction  without 


ARTICULATIONS   OF   OSSICLES.  235 

carrying  the  steel  shell  with  it,  while  in  the  opposite  direction  it 
meets  with  only  slight  resistance.  When  the  handle  of  the 
malleus  moves  inward,  the  inferior  cog  of  the  malleus  catches 
the  inferior  cog  of  the  incus,  and  causes  the  long  process  of  the 
incus  to  follow  the  motion  of  the  handle  of  the  malleus  inward. 
When  the  handle  of  the  malleus  moves  outward,  a  strong  move- 
ment of  the  articular  surfaces  follows,  the  inferior  cog  of  the 
malleus  recedes  from  that  of  the  incus,  and  the  incus  will  con- 
sequently only  follow  the  motion  of  the  malleus  outward  to  a 
slight  extent. ' 

The  articulation  of  the  incus  and  stapes  does  not  admit  of 
much  separation  of  the  bones,  but  they  can  move  sideways  to  a 
greater  extent. 

The  articulation  between  the  stapes  and  the  margin  of  the 
fenestra  ovalis  has  been  the  subject  of  much  microscopical 
study  by  Eisell,  Buck,  and  Brunner.  The  tissue  connecting  the 
margin  of  the  fenestra  ovalis  with  the  margin  of  the  foot-plate 
of  the  stapes  consists  of  elastic,  fibres,  which  run  in  a  radiat- 
ing direction,  converging  toward  the  margin  of  the  foot-plate. 
These  margins  are  covered  with  a  thin  layer  of  cartilaginous 
tissue.  Voltolini  denies  that  there  is  cartilage  in  this  articu- 
lation. 

The  stapedius  muscle  arises  from  the  bottom  of  the  pyramid, 
or  eminentia  stapedii,  the  hollow  of  which  it  fills.  At  the  ori- 
fice of  the  canal  it  becomes  tendinous,  and  thence  runs,  at  an 
obtuse  angle  with  the  rest  of  the  muscle,  to  the  neck  of  the  sta- 
pes. This  is  the  smallest  distinct  muscle  of  the  human  body. 

Although  it  has  been  a  matter  of  discussion  as  to  whether 
the  lining  membrane  of  the  tympanic  cavity  is  a  mucous  or 
serous  membrane,  Politzer,  from  his  own  investigations,  has  no 
doubt  but  that  it  is  a  mucous  membrane.  •  He  thus  agrees  with 
Krause,  Troltsch,  and  Wendt,  who  found  mucous  glands  in  the 
tympanic  cavity.  According  to  Politzer,  vascular  folds  of  mu- 
cous membrane  extend  from  the  walls  of  the  tympanic  cavity 
to  the  ossicles.  These  folds  are  the  means  of  connecting  the 
vessels  in  the  coverings  of  the  ossicles  and  those  of  the  walls  of 
the  cavity.  Besides  these  folds,  Politzer  found  a  number  of  in- 
constant prolongations  of  connective  tissue,  which  were  for- 
merly supposed  to  be  pathological  products,  but  which,  as  he 
was  the  first  to  prove,  are  the  remains  of  the  gelatinous  connec- 
tive tissue  which  fills  the  middle  ear  of  the  foetus. 

Sometimes  the  anterior  portion  of  the  tensor  tympani  is  con- 
nected with  the  tensor  veli  palati.  According  to  Politzer,  in 

1  Lehre  von  den  Tonempfindungen,  p.  217. 


236  MUCOUS   MEMBRANE   OF  TYMPANUM. 

the  new-born  infant  there  is  an  immediate  communication  be- 
tween the  lower  portion  of  the  muscular  cavity  and  the  facial 
canal.  In  adults,  there  are  one  or  more  oblong  fissures  be- 
tween the  eminentia  stapedii  and  the  facial  canal.  In  these 
fissures  the  fibrous  coverings  of  the  connective  tissue  of  the 
muscle  and  the  nerve  come  in  contact  and  amalgamate.1 

5.  The  tensor  tympani  muscle  arises  in  front  of  the  anterior 
opening  of  the  canalis  musculo-tubarius  from  the  pyramid  of  the 
temporal  bone,  from  the  upper  wall  of  the  tubal  cartilage,  and 
from  the  neighboring  border  of  the  sphenoid.     It  passes  over  the 
septum  tubae  into  and  through  the  canal  of  the  tensor  tympani. 
Just  before  leaving  the  canal  it  becomes  tendinous.    The  tendon 
is  inserted  on  the  inner  margin  of  the  handle  of  the  malleus,  at 
the  anterior  edge  of  the  rhomboidal  surface,  obliquely  to  the 
longitudinal  axis  of  the  malleus. 

6.  The  mucous  membrane  of  the  tympanum  is  a  continuation 
of  that  of  the  Eustachian  tube  and  naso-pharyngeal  space.     It 
is  extremely  delicate  and  consists  chiefly  of  an  epithelium  and 
a  layer  of  connective  tissue  underneath.    On  the  lower,  the  an- 
terior portion  of  the  inner,  and  the  posterior  walls,  the  epithe- 
lium consists  mainly  of  columnar  cells  ;  while  on  the  promon- 
tory, roof,   membrana  tympani^  and  ossicles,  pavement  cells 
predominate.     The  thinness  of  the  connective  tissue  is  such 
that  Von  Troltsch  asserts  that  the  mucous  membrane  cannot  be 
separated  from  the  periosteum,  and  that  every  catarrh  is  a  peri- 
ostitis.    But,  according  to  Kessel,  the  connective  tissue  of  the 
mucous  membrane  in  some  places  forms  a  fibrous  framework 
which  separates  it  from  the  periosteum,  and  passes  from  one  pro- 
jection of  bone  to  another  through  the  free  space  of  the  cavity. 
One  such  bridge  has  frequently  been  observed  to  pass  from  the 
eminentia  pyramidalis  to  the  processus  cochleariformis,  while 
many  are  seen  on  the  floor  of  the  tympanum. 

BLOOD-VESSELS. 

The  anterior  and  middle  parts  of  the  tympanic  cavity  are 
supplied — 

1 .  By  the  branches  of  the  ascending  pharyngeal  artery,  from 
the  external  carotid. 

2.  By  branches  of  the  middle  meningeal,  which  pass  through 
the  hiatus  canalis  Fallopii  and  the  petroso-squamosal  fissure 
into  the  tympanic  cavity. 

3.  By  the  internal  carotid,  which  sends  a  few  small  branches 
from  the  carotid  canal  into  the  tympanic  cavity. 

1  Diseases  of  the  Ear,  translation,  p.  43. 


BLOOD-VESSELS   AND   NERVES   OF   TYMPANUN.  237 

Politzer '  has  shown  that  there  is  a  vascular  communication 
between  the  middle  ear  and  the  labyrinth,  through  the  osseous- 
wall  separating  them.  He  says  that  the  blood-vessels  of  the 
middle  ear  can  be  seen  proceeding  from  the  deeper  layers  of  the 
lining  membrane,  accompanied  by  numerous  prolongations  of 
connective  tissue  and  penetrating  almost  perpendicularly  into 
the  bony  substance.  The  blood-vessels  of  the  bony  wall  thua 
connect  the  blood-vessels  of  the  mucous  membrane  of  the  middle 
ear  with  the  vessels  of  the  labyrinth. 

This  vascular  connection  readily  explains  the  easy  trans- 
ferrence  of  disease  of  the  middle  ear  to  the  internal  ear,  a  fre- 
quent clinical  experience.  Yet  the  communication  is  not  so  easy 
as  to  make  it  certain  to  occur  in  every  case. 

NERVES. 

The  tensor  tympani  muscle  is  supplied  by  a  branch  from  the 
otic  ganglion,  and  from  the  internal  pterygoid,  a  branch  of  the 
third  division  of  the  trifacial. 

The  stapedius  is  supplied  by  a  filament  from  the  facial  nerve. 

The  nerves  of  the  mucous  membrane  are  derived  from  the 
tympanic  plexus,  consisting  of  a  combination  of  the  great  sym- 
pathetic, the  trifacial,  and  the  glosso-pharyngeal. 

The  nerves  that  make  up  the  tympanic  plexus,  according  to 
Von  Troltsch,"  are — 

1.  Several    carotico  -  tympanic    nerves,    branches   from    the 
plexus  of  the  sympathetic  in  the  carotid  canal,  which  enter  the 
cavity  of  the  tympanum  through  special  foramina. 

2.  A  twig  of  the  superficial  petrosal  nerve,   entering  the 
cavity  from  above.     It  is  regarded  by  some  as  a  connection  be- 
tween the  otic  ganglion  and  bend  of  the  facial.    Others  consider 
it  a  continuation  of  the  tympanic  nerve  (Jacobson's)  to  the  otic 
ganglion. 

3.  The  ramifications  of  the  tympanic  nerve,  arising  from  the 
glosso-pharyngeus. 

The  otic  ganglion  is  situated  near  the  foramen  ovale  of  the 
greater  wing  of  the  sphenoid  bone,  in  front  of  the  middle  men- 
ingeal  artery,  on  the  outer  side  of  the  cartilage  of  the  Eusta- 
chian  tube,  and  the  point  of  origin  of  the  tensor  palati  muscle. 

It  is  made  up  of  motor  fibres  from  the  third  division  of  the 
fifth  nerve,  of  sensory  fibres  from  the  glosso-pharyngeal,  and  of 
fibres  from  the  great  sympathetic. 

1  Archiv  fur  Ohrenheilkunde,  vol.  xi. 
1  Treatise  on  the  Ear,  translation,  p.  97. 


288  MASTOID   PROCESS. 

Its  branches  of  distribution  are  to  the  tensor  tympani  and 
the  tensor  palati  muscles.  It  sends  a  twig  to  the  external 
pterygoid  branch  of  the  fifth  nerve,  and  several  communicating 
branches  to  the  auricular  nerve  of  the  third  branch  of  the  fifth 
nerve. 

By  this  ganglion  the  soft  palate,  the  drum-head  and  tensor 
tympani,  and  the  integument  of  the  external  ear  are  put  in  re- 
lation with  each  other  and  with  the  general  nervous  system. — 
(Troltsch.) 

The  chorda  tympani  nerve  seems  to  pass  through  the  tym- 
panic cavity  without  being  in  any  physiological  relation  to  it. 
Division  of  this  nerve  in  operations  upon  the  tensor  tympani 
muscle  usually  has  no  effect  upon  the  functions  of  the  ear. ' 

Prussak's  experiments  on  dogs  show  that  irritation  of  the 
cervical  sympathetic  by  the  galvanic  current  causes  contraction 
of  the  blood-vessels.  When  the  irritation  ceased  considerable 
expansion  occurred. 


THE  MASTOID  PROCESS. 

The  mastoid  portion  of  the  temporal  bone  (/*a<rro's,  a  nipple  or 
leat)  is  situated  at  the  posterior  part  of  the  temporal  bone.  Its 
external  surface  is  rough,  and  perforated  by  numerous  fora- 
mina. One  of  these,  of  large  size,  situated  at  the  posterior  bor- 
der of  the  bone,  is  called  the  mastoid  foramen.  Through  it 
a  vein  passes  to  the  transverse  sinus  and  a  small  artery. 

This  roughened  appearance  of  the  mastoid  is  sometimes  so 
marked  that  it  resembles  the  inner  cellular  structure  of  the  bone. 
In  some  rare  cases  there  is  even  complete  absence  of  the  outer 
layer  of  bone,  so  that  the  air  cavities  open  externally,  as  well 
as  into  the  cavity  of  the  tympanum  and  the  external  auditory 
canal. 

Gruber 8  has  seen  emphysema  of  the  neck  and  of  the  occipi- 
tal region  result  from  the  inflation  of  the  cavity  of  the  tym- 
panum in  cases  where  such  external  openings  existed  under  the 
skin. 

This  foramen  does  not  always  exist  in  the  mastoid  process, 
but  is  sometimes  found  in  the  occipital  bone,  or  in  the  suture 
between  the  temporal  and  the  occipital. 

The  mastoid  portion  is  continued  below  into  a  conical  pro- 
jection, which  is  the  true  mastoid  process.  To  this  process  are 

'  See  Chapter  X.  for  an  account  of  the  functions  of  the  chorda  tympani. 
3  Lehrbuch,  p.  32. 


MASTOID   PROCESS. 


239 


attached  the  sterno-mastoid,  the  splenius  capitis,  and  trachelo- 
mastoid  muscles. 

On  the  inner  side  of  the  mastoid  process  is  a  deep  groove, 
called  the  fossa  sigmoidea.  In  this  groove  is  a  part  of  the  lat- 
eral sinus,  and  the  mastoid  foramen  opens  into  it.  The  mastoid 


PIG.  67. — Vertical  Section  through  Right  Temporal  Bone  (anterior  surface  of  posterior 
half,  two-thirds  size.  From  Professor  Darling's  museum).  1,  External  auditory  canal ;  2, 
internal  auditory  canal ;  3,  tympanic  process ;  4,  sup.  semicircular  canal ;  5,  vestibule ;  6, 
styloid  process  ;  7,  mastoid  cells ;  8,  tympanic  cavity. 

process  is  hollowed  out  into  a  number  of  spaces  of  various  size, 
which  are  called  the  mastoid  cells. 


THE  MASTOID  CELLS. 

The  upper  or  horizontal  part  of  the  process,  called  also  the 
antrum  mastoideum,  is  in  communication  with  the  tympanum 
by  means  of  one  or  more  openings  in  the  posterior  tympanic 
wall ;  and  since  it  exists  even  in  the  infant,  before  the  develop- 
ment of  the  mastoid  process,  it  has  been  suggested  that  the 
name  of  "upper  cavity  of  the  tympanum"  would  be  more  ap- 
propriate. The  second  part  of  these  cells,  lying  in  the  mastoid 


240  MASTOID   CELLS. 

process  of  the  temporal  bone,  are  below  the  horizontal  part- 
The  whole  consist  of  a  great  number  of  irregular  spaces  of  vary- 
ing sizes — sizes  that  also  vary  much  in  different  individuals. 
The  whole  are  enclosed  by  a  dense  cortical  layer  of  bone,  sepa- 
rating them  from  the  cavity  of  the  skull,  and  limiting  them  ex- 
ternally. This  cortical  layer  also  is  of  different  thicknesses  in 
different  individuals,  a  fact  of  some  practical  importance  in 
cases  of  suppurative  inflammation  of  the  middle  ear,  implicating 
these  cells. .  Several  small  foramina  are  seen  in  the  mastoid  por- 
tion of  the  temporal  bone — openings  for  branches  of  the  middle 
meningeal  artery  and  the  vasa  emissaria  Santorini. 

The  cells  are  lined  by  a  mucous  membrane  similar  to  that  of 
the  membrana  tympani,  but  it  is  more  delicate. 

The  epithelium  consists  of  smooth  cells  of  the  same  consis- 
tency and  arrangement  as  those  of  the  membrana  tympani. 
Under  this  we  find  two  layers  of  connective 
tissue,  corresponding  to  the  periosteum. 
The  latter  layer  contains  numerous  nerves, 
and  blood-  and  lymph-vessels.  The  upper 
layer  very  frequently  separates  itself  at  the 
free  edge  of  the  cells,  like  a  membrane,  and 
becomes  attached  to  more  closely  lying  tips 
or  projections  of  bone.  By  this  means  the 
cavities  of  two  cells  lying  next  each  other 
become  separated.  In  the  larger  cells  these 
PIG  68  —External  Sur-  membranes  are  stretched  horizontally,  like 
face  of  Left  Mastoid  Bone  curtains,  by  means  of  processes  which  arise 

(from     Professor    Darling's    f  rOHl  them. — (KeSSel.1) 

S^^;€tSJS  ^  birth  the  mastoid  process  is  but  the 
emissary  vein ;  3,  mastoid  rudiment  of  what  it  is  afterward  to  be.  It 
process ;  4,  external  auditory  js  a  small  tuberosity,  and  contains  but  one 
cdl  of  any  considerable  size,  which  after- 
ward  becomes  the  mastoid  antrum. 
Dr.  E.  Zuckerkandl J  was  induced,  by  finding  what  seemed  to 
him  a  remarkable  specimen,  taken  from  a  man  who  died  in 
middle  life,  to  reinvestigate  the  anatomy  of  the  mastoid  pro- 
cess. In  the  first  specimen  that  attracted  his  attention  he  found 
the  cells  even  into  the  antrum  filled  with  diploetic  tissue,  and 
the  adjacent  ones  to  this  latter  part  also  containing  fat.  The 
fat  and  diploe  were  just  the  same  in  appearance  with  that  of 
other  fresh  bones.  The  other  parts  of  the  ear  were  sound.  There 
was  no  trace  of  a  pathological  cause.  His  subsequent  exami- 

1  Handbuch  der  Lehre  von  den  Geweben.     Vierte  Lieferung,  p.  864. 
8  Monatsschrift  f iir  Ohrenheilkunde,  vol.  xiii. ,  No.  4,  1879. 


VARIETIES  IN  MASTOID. 


241 


nations  showed  him  that  in  many  cases  the  mastoid  process  was 
entirely  diploetic  in  structure  or  fully  plugged  with  fat,  and  that 
these  tissues  appeared  together  and  in  connection  with  air-cells. 
Zuckerkandl  examined  250  ears.  He  found  that  the  external 
appearance  gave  no  positive  indication  of  the  internal  structure. 


FIG.  69. — Vertical  Section  through  Right  Temporal  Bone  (posterior  half,  actual  size.  From 
Professor  Darling's  museum).  1,  Squamous  portion  of  temporal  bone  ;  2,  mastoid  process ; 
3,  external  auditory  canal ;  4,  internal  auditory  canal ;  5,  carotid  canal ;  6,  eminence  of  sup. 
semicircular  canal ;  A,  A,  aquaeductus  Fallopii ;  B,  B,  sup.  semicircular  canal ;  C,  C,  hori- 
zontal semicircular  canal ;  7,  mastoid  cells. 

He  found  the  following  varieties  in  the  examination  of  250  tem- 
poral bones : 

1.  The  whole  process  filled  with  air-cells.    The  air-spaces 
more  or  less  of  the  same  size.     The  surface  thin,  in  spots  trans- 
parent. 

2.  The  process  containing  air-cells,  but  the  cavities  small. 

3.  The  cells  of  unequal  size.     Generally  those  of  the  pars 
squamosa  were  larger. 

4.  The  process  entirely  an  air-chamber  (in  toto  lufthaltig). 

16 


242 


VAEIETIES 


MASTOID. 


The  cells  are  large  and  extend  to  a  line  drawn  from  the  lower 
wall  of  the  auditory  canal  through  the  mastoid  process. 

5.  The  cells  of  the  pars  squamosa  were  large,  while  the  pars 
petrosa  of  the  apophysis  contained  one  large  cavity. 

6.  There  were  in  the  whole  process  only  three  or  four  tubular 
cavities,  whose  termini  made  up  the  antrum. 

7.  The  process  involved  only  one  cavity,  on  whose  walls  were 
ridge-like  partitions. 

The  varieties  in  diploetic  and  fatty  contents  were  equally 
great.  Of  100  temporal  bones  belonging  to  50  subjects,  the  mas- 
toid process  was  completely  pneumatic  in  but  40  cases.  In  22 
cases,  the  process  up  to  the  antrum  contained  red  or  yellow 


PIG.  70. — Vertical  Section  of  Left  Temporal  Bone  (actual  size.  From  Professor  Darling's 
museum).  1,  Cochlea  with  lamina  spiralis  ;  2,  external  auditory  canal ;  3,  opening  of  mastoid 
cells ;  4,  plate  of  bone  separating  the  tympanic  cavity  from  carotid  canal ;  5,  squamous  por- 
tion of  temporal  bone  ;  6,  mastoid  process  ;  7,  tympanic  cavity  ;  8,  aquaeductus  Fallopii. 

adipose  tissue.  Nine  times  the  lower  half  of  the  process  was 
diploetic  or  contained  fat,  while  the  upper  part  was  pneumatic, 
and  in  the  remaining  29  cases  only  the  apex,  of  from  3  to  5 
mm.  was  narrow-celled,  diploetic  ;  otherwise  it  contained  air- 
cells.  In  8  of  the  100  cases  the  mastoid  processes  of  the  same 
person  were  different  in  structure.  In  150  macerated  temporal 
bones  the  results  were  as  follows  :  Fifty-two  times  the  process 
was  completely  filled  with  pneumatic  spaces.  Twenty  times 
only  the  lower  half  contained  diploetic  spaces,  while  the  upper 
was  pneumatic.  Thirty-eight  times  the  apex  only  of  the  process 
was  diploetic  from  3  to  5  mm.  Seven  times  the  diploetic  structure 


VARIETIES  IN  MASTOID.  243 

extended  only  to  the  pars  petrosa  of  the  process.  In  summing 
up,  there  are  found  to  be  entirely  pneumatic  processes  in  36.8 
per  cent.  Completely  diploetic,  20  per  cent.  In  42.8  per  cent, 
diploetic  and  pneumatic  cavities  existed  together  in  the  same 
bone.  These  investigations  make  it  probable  that  many,  if  not 
all,  of  the  reported  cases  of  hyperostosis  or  sclerosis  of  the  mas- 
toid  were  really  only  normal  conditions. 

Dr.  Giovanni  Zoja,:  of  Pavia,  examined  sixty-eight  fresh 
preparations,  and  one  hundred  dry  ones,  in  order  to  get  the 
average  size  of  the  mastoid  process  and  its  cavities.  The  result 
of  his  investigations  is  that  the  breadth  of  the  mastoid  is  19  mm., 
its  thickness  13  mm.,  and  its  length  12  mm.  About  one  milli- 
metre should  be  deducted  from  these  measurements  in  the  bone 
of  the  female  subject.  Zoja  does  not  confirm  Velpeau's  view, 
that  the  mastoid  process  is  more  developed  in  advanced  life. 
The  cortical  layer,  according  to  these  examinations,  has  an  aver- 
age thickness  of  from  one  to  two  millimetres. 

In  two  of  the  sixty-eight  specimens  belonging  to  one  subject 
the  cells  were  united  into  one  large  cavity,  so  that  they  formed, 
as  it  were,  a  mastoid  cavity.  This  was  also  found  in  another 
case  on  one  side  only.  The  cells  in  the  centre  of  the  process  are 
usually  the  larger,  and  communicate  with  one  another,  if  they 
are  not  separated  by  the  membrane  that  has  been  described.  In 
several  cases  there  were  cells  only  in  the  base  of  the  process. 
Occasionally  these  cells  extended  to  the  side  of  the  skull,  or  even 
to  the  middle  of  the  petrous  part  of  the  temporal  bone. 

Dr.  Zoja  thinks  that  the  development  of  the  cellular  structure 
goes  on  in  a  kind  of  system.  They  become  gradually  larger, 
and  are  lined  with  a  peculiar  membrane  ;  in  the  spaces  a  gela- 
tinous mass  is  found,  which  becomes  gradually  serous,  and  is 
either  taken  up  by  the  vessels  of  the  cavities  or  passes  into  the 
cavity  of  the  tympanum,  where  it  is  absorbed. 

In  five  of  the  sixty-eight  specimens  the  antrum  was  found  to 
be  separated  from  the  other  cellular  spaces  by  a  membranous 
partition.2 


BLOOD-VESSELS  OF   THE  MASTOID   PROCESS. 

The  blood-supply  of  the  mastoid  cells  is  furnished  by  the 
stylo-mastoid  branch  of  the  posterior  auricular  artery,  while 
their  nerves  come  from  the  tympanic  plexus. 


1  Gruber's  Lehrbuch,  p.  33. 
1  Henle  :  Lehrbuch,  p.  751* 


244 


EUSTACHIAN  TUBE. 


THE  EUSTACHIAN  TUBE. 


The  Eustachian  tube,  like  the  external  auditory  meatus,  con- 
sists of  an  osseous  and  a  cartilaginous  part.     The  former  meas- 


FIG.  71. — Section  of  the  Head,  showing  the  Divisions  of  the  Ear  and  the  Naso-pharyngeaL 
Cavity  (after  a  photograph — Riidinger).  1,  Cartilage  of  external  auditory  canal ;  2,  osseous 
auditory  canal ;  3,  4,  membranae  tympanorum  ;  5,  cavity  of  the  tympanum  ;  6,  dilator  muscle 
of  the  Eustachian  tube ;  7,  levator  palati  muscle ;  8,  mucous  membrane  of  the  pharyngeal 
orifice  of  the  tube  ;  9,  left  membrana  tympani  ;  10,  handle  of  the  malleus  and  short  process  ; 
11,  tensor  tympani  muscle ;  12,  mucous  membrane  of  the  membranous  portion  of  the  tube, 
perforated  by  a  needle  ;  13,  levator  veli  palati  muscle  ;  14,  mucous  membrane  of  the  posterior 
surface  of  the  pharynx  ;  1 5,  mucous  membrane  of  the  pharynx,  attached  to  the  lower  surface 
of  the  body  of  the  sphenoid  bone ;  16,  sphenoidal  sinus ;  17,  hypophysis  cerebri  and  its  rela- 
tions to  the  cerebral  arteries  and  the  cavernous  sinus. 

ures  11  mm.,  the  latter  24  mm.,  so  that  the  whole  length  of  the 
tube,  from  its  opening  into  the  tympanic  cavity  to  its  pharyngeal 
orifice,  measures  35  sam.  The  tube,  from  its  tympanic  end,. 


EUSTACHIAN  TUBE. 


245 


runs  forward,  inward,  and  downward.  Its  axis  makes  an  angle 
of  135°  with  the  axis  of  the  external  auditory  canal,  and  an  angle 
of  40°  with  the  horizontal  plane. 

The  diameter  of  the  osseous  portion  of  the  tube  is  about 
2  mm.  The  walls  are  smooth,  and  covered  by  a  mucous  mem- 
brane, which,  like  that  of  the  tympanum,  is  closely  adherent  to 
the  periosteum.  The  lateral  wall  belongs  to  the  pars  tympanica ; 
the  median  wall  separates  the  tube  from  the  carotid  canal ;  the 
upper  wall  is  formed  by  the  septum  tubae,  the  floor  of  the  canal 
for  the  tensor  tympani  muscle. 

The  shape  of  the  anterior  extremity  of  the  osseous  tube  is 
very  irregular,  the  inner  wall  extending  forward  much  further 
than  the  lateral  wall.  This  part,  ''the 
isthmus,"  is  the  narrowest  portion  of 
the  tube.  Here  the  tube  gradually 
widens,  and  ends  anteriorly  in  a  trum- 
pet-shaped orifice  9  mm.  high  and  5 
mm.  broad,  which  projects  slightly 
into  the  post-nasal  space,  and  ]jes  a 
little  above  the  level  of  the  floor  of  the 
nostril. 

The  cartilage  of  the  tube  is  made 
up  of  two  plates — a  median  and  a 
lateral.  The  median  plate,  which  is 
much  the  larger,  is  triangular,  and 
into  its  upper  and  outer  part  is  inserted 
the  hook-shaped  and  smaller  lateral 
cartilage.  But  most  of  the  lateral 
wall  and  all  of  the  lower  is  formed  of 
membrane  instead  of  cartilage,  the 
membrane  forming  nearly  a  half  of 
the  circumference  of  the  tube. 

„,,  -..  •..,       f    ,t  ,-i  spheno-staphylinus  muscle. 

The  median  wall  of  the  cartilage 

of  the  tube  is  below  1  mm.  in  thickness  on  its  posterior  extrem- 
ity, but  increases  in  size  gradually  to  2£  to  3  mm.,  and  on  its 
free  anterior  border  may  even  reach  7  mm.  The  tissue  of  the 
cartilage  is  chiefly  hyaline,  but  it  has  a  fibrous  base  substance 
at  various  spots  ;  sometimes  on  the  surface,  sometimes  on  the 
interior,  and  especially  near  the  edges. 

The  mucous  membrane  which  fills  up  the  concavity  of  the 
cartilage,  and  which  changes  the  calibre  up  to  the  vicinity  of 
the  pharyngeal  orifice  to  a  plane  surface,  is  0.6  mm.  thick  at  its 
densest  portion.  It  is  connected  to  the  perichondrium  by  loose 
connective  tissue.  It  is  made  smooth  by  numerous  acinose 
glands  of  about  0-6  mm.  in  diameter  and  0.15  mm.  in  thickness. 


FIG.  72. — Transverse  Section  of 
Upper  Part  of  the  Eustachian  Tube 
(after  Henle).  *,  Fibres  of  the 


246 


EUSTACHIAN   TUBE. 


These  glands  form  a  continuous  layer  backward  from  the  phar- 
yngeal orifice  for  some  distance.  Toward  the  cavity  of  the  tym- 
panum they  are  less  numerous,  yet,  according  to  Von  Troltsch, 
they  are  found  on  the  tympanic  orifice.  Toward  the  pharyngeal 
orifice  large  mucous  glands  appear  lying  on  the  outer  side  of  the 
cartilage. 

The  lateral  wall  of  the  tube,  which,  with  its  upper  border, 
bounds  the  convex  surface  of  the  enveloping  ridge  of  the  car- 
tilage, has  about  the  same  thickness  as  the  median  wall,  and  the 
same  covering  of  mucous  membrane.  The  tissue  in  the  upper 
half  is  quite  firm,  in  the  lower  more  relaxed  and  spongy.  Fat  is 
its  chief  structure. 

A  portion  of  the  tendinous  origin  of  the  spheno-staphylinus 
muscle  unites  with  the  firmer  portion  of  the  wall,  and  for  some 


FIG.  73. — Transverse  Section  through  the 
Lower  End  of  the  Eustachian  Tube  (after 
Henle).  *,  Mucous  glands ;  **,  fibres  of  petro- 
staphylinus  muscle. 


FIG.  74. — Transverse  Section  through 
the  Lower  End  of  the  Eustachian  Tube  (af- 
ter Henle).  *,  Mucous  glands ;  **,  trans- 
verse section  of  the  petro-staphylinus 
muscle. 


distance  this  origin  runs  in  a  thin  layer  between  the  upper  bor- 
der of  the  soft  wall  of  the  tube,  and  unites  with  the  convex  sur- 
face of  the  latter. 

The  spheno-staphylinus  muscle  being  thus  attached  to  the 
tube  has  the  power  of  rolling  over  the  upper  inverted  border  of 
the  cartilage,  and  of  enlarging  the  angle  which  the  lateral  wall 
forms  with  the  median.  The  opening  or  gaping  of  the  tube  de- 
pends upon  this  action,  which  occurs  with  the  act  of  swallowing. 

At  the  point  where  the  lateral  wall  of  the  nasal  cavity  passes 
into  the  pharynx,  at  the  same  height  with  the  posterior  point  of 
the  inferior  turbinated  bone,  lies  the  pharyngeal  orifice  of  the 
tube  (Fig.  75). 

Since  the  inner  wall  of  this  canal  projects  into  the  calibre  of 
the  naso-pharyngeal  space,  the  mouth  of  the  tube  lies  more  in  a 


EUSTACHIAN   TUBE.  247 

frontal  than  sagittal  plane.  It  has  a  puffy  median  border,  while 
the  lateral  wall  passes  without  any  distinct  line  of  separation 
into  the  nasal  cavity.  The  width  of  the  mouth  of  the  tube 
varies  in  different  persons,  and  has  the  general  shape  of  a 
funnel. 

According  to  Riidinger/  the  minute  differences  in  form  of 
the  Eustachian  tube  in  animals  are  so  characteristic,  that  from  a 
section  of  the  Eustachian  tube  the  animal  from  which  it  has 
been  taken  can  be  designated. 

The  known  functions  are  to  conduct  away  the  secretions  of 
the  cavity  of  the  tympanum,  and  to  act  as  a  ventilator  of  this 
part.  What  part  it  has  to  do  with  the  conduction  of  sound  to 


FIG.  75. — Vertical  Section  showing  the  Mouth  of  Eustachian  Tube  and  Rosenmuller's  Fossa^ 

the  ear,  or  what  connection  it  has  with  the  voice,  has  not  as  yet 
been  determined.  Riidinger  has  observed  fatty  degeneration  of 
the  tubal  cartilage  of  man,  and  it  may  be  conceived  that  fatty 
degeneration  of  its  muscles  may  occur  in  some  subjects  and  be- 
come a  serious  impediment  to  the  performance  of  its  functions. 

The  mucous  membrane  of  the  tube  is  at  its  lower  part  quite 
thick,  like  that  of  the  pharynx,  of  which  it  is  an  immediate  con- 
tinuation. Its  epithelium  is  ciliated,  the  motion  being  in  the 
direction  of  the  pharynx.  This  anatomical  fact  explains  the 
intolerance  which  this  membrane  displays  toward  the  injection 
of  fluids  from  the  pliaryngeal  orifice.  The  tube  of  the  infant 
differs  much  from  that  of  the  adult.  It  is  shorter,  wider,  and 
more  nearly  horizontal. 

2  Strieker's  Hand-book,  p.  973.  ' 


248 


EUSTACHIAIs    TUBE. 


Riidinger  divides  the  fissure  of  the  tube  into  two  portions. 
There  is  a  semi-cylindrical  space  under  the  hook  of  the  carti- 
lage which  he  calls  the  safety  tube,  and  the  fissure  connecting 
with  it  the  accessory  fissure. 

Both  divisions  are  produced  by  the  shape  of  the  cartilage, 
and  are  separated  from  each  other  by  projections  of  mucous 
membrane.  The  mucous  membrane  is  firmly  attached  to  the 
tissues  about  it  on  the  concavity  of  the  hook  ;  but  at  that  point 
where  the  accessory  fissures  begin,  fold-like  projections  are  pro- 
duced between  this  fissure  and  the  safety  tube.  The  projection 


FIG.  76.— Transverse  Section  of  Eustachian  Tube  and  Surrounding  Parts  (after  Rudinger). 
1,  Median  cartilaginous  plate ;  2,  lateral  cartilaginous  hook ;  3,  dilator  of  the  tube ;  4,  lava, 
tor  of  the  soft  palate  ;  5,  basilar  fibre-cartilage :  6,  7,  acinous  glands ;  8,  fat  in  the  lateral 
wall ;  9,  safety  tube ;  10,  accessory  fissure  ;  11,  fold  of  mucous  membrane ;  12,  adjacent  tissues. 

of  these  folds  prevents  the  safety  tube  from  being  closed.  The 
closure  is  first  possible  at  the  point  where  the  bend  of  the  carti- 
lage becomes  narrower,  and  the  mucous  membrane  is  not  closely 
united  with  it.  This  point  is  at  about  the  middle  of  the  tube, 
where  the  mucous  membrane  has. a  slightly  undulating  surface, 
as  seen  in  Fig.  78. 

The  question  whether  the  tube  is  normally  open — that  is, 
when  the  muscles  of  deglutition  are  at  rest — is  one  which  has 
been  much  debated.  Throughout  the  narrowest  part  of  the  tube 


EUSTACHIAN   TUBE.  249 

the  larger  part  of  the  outer  and  inner  walls  are  in  contact,  but 
at  the  upper  part  is  a  small  chink,  which,  as  some  authors 
claim,  remains  patent,  while  others  deny  this.  However,  any 
observer  with  normal  tubes  will  be  able  to  notice  that  the  tube 
opens,  or  at  least  widens,  at  every  act  of  swallowing.  If  the 
nostrils  are  tightly  held,  air  will  be  pumped  out  of  the  tym- 
panum by  the  act  of  swallowing,  and  this  air  will  be  restored 
again  to  the  ear-drum  by  swallowing  with  the  nostrils  free. 

MUSCLES  OF  THE  TUBE. 

The  muscular  apparatus  of  the  Eustachian  tube  also  belongs 
to  the  pharynx.    Indeed,  these  parts  are  so  closely  connected  in 


PIG.  77.— Section  of  the  Upper  Third  of  the  Eustachiau  Tube  (after  Riidinger).  1,  Me- 
dian cartilage ;  2,  lateral  cartilage  hook ;  3,  perichondrium  ;  4,  submucosa ;  5,  insertion  of 
the  dilator  of  the  tube ;  6.  safety  tube ;  7,  lateral  projection  of  the  mucous  membrane  ;  8, 
median  projection  of  the  mucous  membrane  ;  9,  accessory  fissure. 

all  their  structures,  that  an  affection  of  one  part  independent  of 
the  other  can  hardly  be  said  to  occur. 
The  muscles  of  the  tube  are — 

1.  THE  ABDUCTOR  OR  DILATOR  OF  THE  TUBE. — This  muscle 
is  also  known  as  the  spheno-salpingo  staphylinus  muscle,  the 


250 


MUSCLES   OF   EUSTACHIAN   TUBE. 


circumflexus  palati,  or  tensor  palati  mollis.     It  is  probably  the 
most  important  muscle  of  the  tube. 

This  muscle  arises  from  the  sphenoid  bone  and  the  cartilage 
of  the  tube.  It  is  inserted  on  the  blunt  edge  of  the  cartilaginous 
plate  along  the  whole  length  of  the  canal.  It  passes  forward, 
inward,  and  downward,  and  its  fibres  spread  out  along  the  edge 
of  the  soft  palate,  and  011  the  side  of  the  pharynx.  It  enlarges 
the  calibre  of  the  tube  by  drawing  the  hook  of  the  cartilage  for- 
ward and  a  little  downward. 


FIG.  78.— Section  of  the  Middle  Third  of  the  Eustachian  Tube  (after  Rudinger).  1,  2, 
Cartilage  ;  3,  dilator  of  the  tube  ;  4,  folds  of  mucous  membrane  under  the  cartilage  hook  ;  5, 
folds  of  mucous  membrane  in  the  accessory  fissure  ;  6,  submucosa. 


Riidinger  confirms  the  view  expressed  by  Von  Troltsch  and 
Mayer  that  the  dilator  of  the  tube  passes  directly  into  the  tensor 
tympani  muscle  This  is  true  not  only  of  the  tendons,  but  also 
of  the  muscular  fibres. 

Rudinger  compares  the  rolling  of  the  muscle  about  the  ham- 
ular  process  of  the  pterygoid  plate  of  the  sphenoid,  to  the  pulley 
arrangement  of  ^ie  superior  oblique  muscle  of  the  eye.  This 
attachment  is  certainly  a  point  of  fixation  in  the  movements  of 
the  muscle. 


MUSCLES   OF   EUSTACHIAN  TUBE.  251 

2.  THE  LEVATOR  VELI  PALATI. — This  muscle  is  not  very  in- 
timately connected  with  the  tube,  and  yet  it  plays  an  important 
part  in  its  mechanism.     It  arises  with  a  cylindrical  tendon  on 
the  lower  surface  of  the  temporal  bone,  on  the  anterior  border 
of  the  entrance  to  the  carotid  canal,  and  by  a  few  fibres  from 
the  cartilaginous  portion  of  the  tube. 

In  the  soft  palate  the  muscles  of  the  two  sides  are  closely 
connected.  From  this  point  they  separate,  and  each  one  runs 
upward,  and  is  firmly  attached,  in  the  vicinity  of  the  osseous 
tube,  not  only  on  the  bone,  but  also  to  the  cartilage  and  the 
mucous  membrane  of  the  tube. 

When  this  muscle  contracts,  by  its  becoming  thicker,  the 
membranous  floor  of  the  tube  is  pressed  forward,  and  thus  the 
long  diameter  of  the  tube  is  shortened,  and  the  transverse  di- 
ameter is  enlarged,  that  is  to  say,  it  is  made  to  gape  *ery 
widely.1  The  salpingo-pharyngeus  muscle  also  assists  in  this 
action. 

3.  THE  SALPINGO-PHARYNGEUS  (RUDINGER). — This  is  a  thin 
muscular  layer,  that  passes  from  the  lower  end  of  the  tube  ob- 
liquely downward  and  backward,  and  is  connected  to  the  lower 
end  of  the  median  cartilaginous  plate,  and  to  the  mucous  mem- 
brane.    It  is  inserted  in  the  posterior  wall  of  the  pharynx.     Rii- 
dinger  considers  this  thin  muscle  to  be  a  fixator  of  the  median 
cartilaginous  plate,  in  its  various  positions  caused  by  the  con- 
traction of  the  constrictor  of  the  pharynx  and  the  levator  palati. 

The  opening  of  the  Eustachian  tube  is  the  result  of  a  combi- 
nation of  muscular  action.  If  the  three  muscles  are  innervated 
simultaneously,  and  their  contractions  occur  at  the  same  time, 
the  hook-shaped  cartilage  is  fixed  by  the  dilator  of  the  tube  and 
drawn  outward,  the  concave  portion  of  the  tube  becomes  a  little 
less  curved,  and  the  semi-cylindrical  gutter  is  widened.  If  the 
levator  of  the  velum  contract,  the  space  of  the  tube  at  the  pha- 
ryngeal  orifice  is  enlarged  more  than  three  lines. 

If  the  muscles  cease  to  act,  the  elasticity  of  the  cartilage 
comes  into  play,  the  canal  becomes  narrower,  without  being 
at  its  lower  section  completely  closed,  however.2  Respiratory 
movements  of  the  membrana  tympani  have  been  often  observed, 
and  these  occur  through  this  gap  in  the  tube,  which  cannot  be 
said  to  be  ever  firmly  closed.  Any  one  who  has  often  climbed 
high  mountains  and  has  become  "out  of  breath"  from  exertion 
in  reaching  the  top,  must  have  observed  in  his  own  ears  this 

1  Riidinger :  Beitrage  zur  vergleichenden  Anatomie  und  Histologie  der  Ohrtrom- 
pete.  *  Riidinger,  loc.  cit. ,  p.  7. 


252  DISCOVERY   OF   EUSTACHIAN   TUBE. 

continuation  of  respiration  through  the  tube.  This  fact  throws 
light  upon  the  etiology  of  cases  of  diseases  of  the  middle  ear, 
arising  from  inflammations  of  the  respiratory  organs,  such  as 
pneumonia  and  bronchitis. 

BLOOD-VESSELS. 

1.  The    ascending    pharyngeal    artery,    from    the    external 
carotid. 

2.  The  internal  maxillary,  the  larger  of  the  two  terminal 
branches  of  the  external  carotid,  also  supplies  the  Eustachian 
tube  by  its  middle  meningeal  branch. 

3.  Branches  of  the  internal  carotid  artery. 

NERVES. 

1.  The  internal  pterygoid,  a  branch  of  the  third  division  of 
the  fifth  nerve,  sends  a  supply  to  the  dilator  of  the  tube. 

2.  The  superior  pharyngeal,  a  branch  of  the  second  division 
of  the  fifth  nerve,  sends  branches  to  the  pharyngeal  orifice. 

3.  The  glosso-pharyngeal  supplies  the  mucous  membrane. 

4.  The  pneumogastric  supplies  the  levator  veli  palati  muscle. 

Historical. — The  history  of  the  successive  steps  by  which  the 
Eustachian  tube,  has  taken  its  true  and  important  position  with 
relation  to  the  study  and  treatment  of  aural  disease,  is  a  very 
interesting  one,  and  has  been  very  succinctly  given  by  Dr. 
Ludwig  Mayer,1  from  whose  writings  I  have  already  quoted  in 
the  chapter  on  "Foreign  Bodies." 

As  has  been  said  on  page  4,  Alcmeon  and  Aristotle  knew  of 
the  Eustachian  tube,  but  Eustachius  was  the  first  writer  who 
gave  an  exact  description  of  it.  This  is  found  in  the  edition  of 
his  anatomical  works  published  in  Venice  in  1564. a 

The  passage  in  reference  to  the  tube,  as  quoted  by  Mayer,  is 
as  follows : 

Ergo  a  caverna  ossis  lapidei,  in  quam  meatus  auditorius,  conchion  appellatus 
finitur,  via  in  narium  cavitatem  perforata  est :  ab  ilia  enim  meatus  alter  oritur 
rotundo  canaliculo  similis,  et  instar  tenuioris  calami  aniplus,  qui  oblique  ad 
interius  interiusque  basis  capitis  latus  procedens,  in  medio  quatuor  foraminum, 
totum  istud  os  penetrat  atque  perfodit.  na  posteriori  ipsius  sede  arteria  soporaria 
calvaria  ingreditur :  anteriori  quartum  nervorum  cerebri  jugum  extra  ipsam 
emergit :  externurn  latus  arterise  in  dura  cerebri  membrana  distributee  adituin 

1  Studien  iiber  die  Anatomie  des  Canalis  Eustachii.     Miinchen,  1866. 
1  Bartholomaei  Eustachii  Opuscula  Anatomica. 


EUSTACHIAN   TUBE.  253 

patefacit :  internum  denique  fissura  quaadam  circumscribit,  quaa  a  cuneum 
referentis  ac  lapidei  ossis  extremis  partibus,  oblique  infra  et  anteductis,  fit. 
Caeteruin  hunc  meatum,  de  quo  sermo  est,  arbitrabitur  fortasse  quispiam  eo  loco 
desinere ;  res  autem  non  ita  se  habet,  sed  alterius  generis  substantia  auctum, 
inter  duos  faucium  seu  guise  musculos,  &  paucis  hucusque  bene  cognitos  secun- 
dum,  paulo  ante  me  moratse  fissurse  ductum  ulterius  procedit ;  et  juxta  radicem 
intemaa  partis  apophysis  ossis  alis  vespertilionum  similis  in  alteram  narium 
cavitatem  terminatur ;  et  in  crassam  palati  tunicam  prope  radicem  gargareonis 
inseritur.  Substantia  sane  ejus,  qua  extrema  fissurse  ossi  temporum  et  cuneo 
simili  communis  tangit,  cartilaginea  est  ac  admodum  crassa ;  huic  vero  appositae 
partis  substantia  exacta  cartilage  non  est,  sed  membranosum  nescio  quid  habet, 
et  tenuior  evadit  a  hujus  meatus  intena  extremitas  narium  cavitatis  medium 
respicies  robusta  est  cartilage,  quaa  plurimum  extuberat,  mucosaque ;  narium 
tunica  obducitur,  ac  fini  ejusdem  meatus  quasi  canitor  prseferta  esse  videtur, 
figura  teres  non  est,  sed  aliquantum  depressa  duos  efficit  angulos :  latitude 
cavitatis  calamum,  quo  scribimus,  fere  adsequat,  sed  in  fine  duplo  latior  est, 
quam  in  principio,  quae  similiter  mucosa  sed  tenui  induitur  tunica.  Hoc  calli- 
dissimum  naturae  artificium  a  me  inventum  contemni  (ut  opinor)  non  debet : 
siquidem  turn  philosopbis,  turn  niedicis  non  parum  utilitatis  afferre  potest.  nam 
antiquiores  philosophi,  quorum  numero,  ut  Aristoteles  refert  primo  de  natura 
animalium  undecimo  fuit  Alcmeon,  capras  non  modo  ore  ac  naribus,  verum  etiam 
auribus  quoque  spirare,  forte  ob  earn  causam  arbitrati  sunt,  quod  meatum  quam 
descripsi  non  ignorarent  atque  adeo  saepius  experti  fuissent  spiritum,  ubi  ipsum 
quis  cohibet,  ad  aurium  cavitatem  vi  quadam  impulsum  recurrere,  et  instar 
fluctus,  auditus  organa  percutere.  Erit  etiam  niedicis  hujus  meatus  cognitio, 
ad  rectum  medicamentorum  usum  maxime  utilis,  quod  scient  post  hac  ab  auribus, 
non  augustis  foraminibus,  sed  amplissima  via  posse  materias  etiam  crassas,  vel  a 
natura  expelli,  vel  medicamentonim  ope,  quse  masticatoria  appellantur,  com- 
mode expurgari. 

The  last  paragraph  of  this  quotation  shows,  that  Eustachius 
anticipated  an  earlier  use  of  his  discovery,  than  was  made  by  the 
profession. 

The  writers  who  followed  Eustachius  up  to  Valsalva's  time, 
based  their  labors  on  what  Eustachius  had  done.  Mayer,  in 
order  to  express  his  estimate  as  to  their  value,  quotes  Goethe, 
who  says  :  "  Denn  eben  wo  Begriffe  fehlen,  da  stellt  ein  Wort 
zur  rechten  Zeit  sich  ein."  Where  an  idea  is  wanting,  a  word 
can  be  put  in  its  place. 

Valsalva,  however,  described  the  muscles  of  the  Eustachian 
tube  very  exactly,  but  a  hundred  and  twenty-five  years  after 
Eustachius.  He  supposed  that  the  function  of  the  muscles  was 
to  keep  the  tube  constantly  open.  It  was  not  until  1850  that  the 
anatomical  descriptions  began  to  be  accurate.  Then  F.  Arnold, 
in  his  "Handbuch  der  Anatomic  des  Menschen,"  published  at 
Freiburg  in  Bresgau,  in  1851,  gave  a  careful  description  of  the 
tube.  Merkel  ("Anatomic  und  Physiologic  der  menschlichen 
Stimme  und  des  Sprech-Organs  ")  and  Tortual  ("Neuen  Unter- 


254  PHYSIOLOGY   OF   MIDDLE  EAR. 

suchungen  iiber  den  Bau  des  menschlichen  Schlundes  und  Kehi- 
kopfes  "),  1861,  afterward  described  the  canal.  Von  Troltsch,1  in 
an  article  published  in  his  "  Archives,"  elaborated  the  subject 
much  farther.  The  labors  of  Mayer  and  Rudinger  have  brought 
our  knowledge  of  the  anatomical  structure  to  the  present  stage. 
It  should  never  be  forgotten  that  Joseph  Toynbee,  was  the 
first  writer,  in  a  paper  presented  to  the  Royal  Society  in  1851,  to 
show  that  the  faucial  orifice  was  controlled  by  the  muscles  of 
the  palate,  and  that  the  act  of  swallowing  affected  the  calibre  of 
the  tube.  Toynbee  thought  that  the  tube  was  completely  closed 
in  a  state  of  repose,  and  although  not  strictly  correct  in  this,  his 
labors  can  hardly  be  overestimated. 

PHYSIOLOGY  OF  THE  MIDDLE  EAR. 

The  waves  of  sound  may  reach  the  endolymph  of  the  laby- 
rinth, through  the  bones  of  the  skull.  It  is  with  difficulty,  how- 
ever, that  sonorous  vibrations  are  transmitted  from  the  air  to 
solids  and  liquids.  A  special  apparatus  to  secure  their  trans- 
mission is  found  in  the  middle  ear,  for,  as  we  have  seen,  the 
external  ear  has  a  very  small  share  in  this  function. 

Functions  of  the  Membrana  Tympani. 

The  presence  of  the  membrana  tympani,  in  whole  or  in  part, 
is  not  essential  to  fair  hearing  power.  This  was  first  clearly 
proven  by  Sir  Astley  Cooper,8  in  a  case  of  which  more  will  be 
found  in  the  discussion  upon  paracentesis  of  the  drum-head,  in 
a  subsequent  chapter  ;  but,  that  it  is  very  important  to  good 
hearing  in  some  cases,  is  shown  by  the  numerous  instances  in 
which  an  artificial  membrana  tympani  raises  the  hearing  power 
from  a  very  low  degree  to  a  high  one.  The  membrana  tympani 
is  perhaps  more  properly  considered  as  the  outer  expansion  of 
the  ossicula  auditus,  for  it  is  so  intimately  connected  with  the 
malleus,  as  to  be  essentially  a  part  of  the  chain  of  bones  that 
conducts  sound  to  the  endolymph  of  the  labyrinth.  Very  great 
thickening  of  the  drum-head,  that  is  to  say,  of  its  fibrous  and 
mucous  layers,  must  of  necessity  involve  the  insertion  of  the 
malleus  which  is  in  its  layers,  so  that  we  can  hardly  speak  of 
the  functions  of  the  membrana  tympani  without  including  those 
of  the  ossicles.  Yet  there  are  a  few  points  in  its  physiology 
that  may  be  mentioned  by  themselves.  Wollaston 3  snowed  that 

1  Archiv  fiir  Ohrenheilkunde,  Bd.  I.,  Heft  i.,  p.  15. 
*  Philosophical  Transactions,  p.  155.    1800. 
•Ibid.,  p.  306.    1820. 


PHYSIOLOGY    OF  MIDDLE   EAK.  255 

if  the  membrana  tympani  be  rendered  very  tense,  the  ear  is 
rendered  insensible  to  low  sounds,  but  those  of  a  high  pitch  are 
made  more  intense.  Blake '  also  found  that  in  two  cases  of 
voluntary  contraction  of  the  tensor  tympani  muscle,  the  percep- 
tion increased  from  3000  to  5000  vibrations  during  the  contrac- 
tion of  the  muscle.  Blake  also  showed  that  in  a  membrane 
slightly  opaque  and  not  very  concave,  but  with  a  number  of 
small  calcareous  deposits  on  a  line  with  the  lower  end  of  the 
process  of  the  malleus,  the  perception  of  high  tones  was  greatly 
increased  by  an  opening  made  in  the  drum-head. 

The  peculiar  formation  of  the  membrana  tympani,  it  being 
of  the  shape  of  a  funnel  with  a  depressed  centre,  surrounded  by 
sides  somewhat  convex,  make  it,  according  to  the  physicists, 
peculiarly  susceptible  to  sonorous  vibrations,  and  it  is  easily 
thrown  into  corresponding  movements  when  waves  of  sound 
enter  the  auditory  canal  and  strike  upon  it.  The  membrana 
tympani  probably  has  no  fundamental  tone  of  its  own,  or  that 
tone  has  not  been  exactly  determined.  It  is  not  thrown  into 
vibrations  by  waves  of  a  particular  length  more  readily  than  by 
others.1  Had  the  membrane  its  peculiar  fundamental  note,  we 
should  be  distracted  by  its  prominence  in  the  ordinary  sounds 
of  life.  Hensen s  says,  and  has  proven  by  experiment,  that  the 
membrana  tympani  is  toned  to  a  relatively  deep  note  as  the  re- 
sult of  its  funnel-like  shape.  Hensen  also  states  that  perhaps 
the  peculiar  note  of  the  drum-head,  may  be  produced  by  blowing 
air  into  the  auditory  canal.  This  tone,  he  says,  cannot  be  ex- 
actly determined,  but  it  is  certainly  not  higher  than  700  vibra- 
tions. But,  he  adds,  it  is  doubtful  if  a  precise  tone  can  be 
assigned  to  such  an  un  symmetrical  membrane. 

Seebeck  and  Mach,  quoted  by  Hensen,4  say  that  the  regu- 
larity of  our  perception  of  tones  is  due  to  the  deadening  of 
sounds  produced  by  the  ossicles  and  the  fluid  of  the  labyrinth. 
It  is  probable  that  the  membrana  tympani  can  only  be  properly 
considered  as  a  sound  conductor  in  connection  with  the  ossicles. 
It  has  one  function  entirely  its  own,  however,  which  is  of  the 
highest  importance.  It  is  the  protecting  membrane  of  tlu3  tym- 
panic cavity,  although  its  complete  destruction  or  great  thicken- 
ing of  its  layers,  may  not  destroy  the  power  of  hearing.  Even  if 
a  fair  hearing  of  speech  and  music  remain  when  it  \s  removed, 
the  tympanum  is  deprived  of  a  covering  which  is  essential  to  its 
continuation  in  health.  As  is  seen  in  the  study  of  chronic  sup- 

1  Transactions  of  the  American  Otological  Society,  p.  77.    1872. 

s  M.  Foster's  Physiology,  p.  575.  J  Hermann's  Handbuch,  p.  42. 

4  Loc.  cit.,  p.  43. 


256  FUNCTIONS    OF   OSSICULA    AUDITUS. 

purations  of  the  middle  ear,  when  the  membrana  tympani  is 
destroyed  or  even  partially  removed,  the  tympanum  is  exposed 
to  a  series  of  dangers,  any  one  of  which  may  be  destructive  not 
only  of  the  hearing  but  of  the  life.  To  preserve  and  quickly  re- 
store an  ulcerated  membrana  tympani,  becomes  therefore  a  very 
important  duty. 

Ossicula  Auditus. 

Many  observations  have  been  made  upon  the  vibrations  of 
the  ossicula  auditus  by  Politzer,  Blake,  Buck,  Mach,  Kessel, 
Hensen,  Burnett,  Helmholtz,  and  others.1 

The  action  of  the  malleus  and  incus  has  excited  considerable 
attention.  Helmholtz 3  has  shown,  as  has  been  already  noticed, 
that  when  the  malleus  is  carried  inward,  the  incus  also  moves 
inward,  and  when  the  malleus  returns  to  its  position,  the  incus 
returns  with  it.  Its  saddle-shaped  joint  with  cog-teeth  permits 
this  movement,  while  it  prevents  the  stapes  from  being  pulled 
back  when  the  membrana  tympani  and  the  malleus  are  pushed 
out  more  than  usual.  The  joint  then  separates,  so  that  the  mal- 
leus may  be  moved  alone.  The  ligaments  also  serve  to  keep 
the  malleus  in  place.  The  bones  conduct  vibrations  as  a  single 
solid  lever,  the  fulcrum  of  which  is  situated  at  the  attachment 
by  ligament  of  the  short  process  of  the  incus  to  the  posterior 
wall  of  the  tympanum. 

Every  movement  of  the  membrana  tympani  is  transferred 
through  the  ossicles  to  the  membrane  of  the  fenestra  ovalis,  and 
to  the  perilymph  of  the  labyrinth.  The  vibrations  are  increased 
in  intensity,  but  diminished  in  amplitude  when  they  reach  the 
perilymph.  It  is  generally  conceded  that  the  ossicles  have  no 
independent  vibrations  that  can  be  perceived,  but  that  they  act 
as  a  single  solid  body  in  conveying  vibrations  to  the  labyrinth. 

Tensor  Tympani  Muscle. 

Even  when  the  tensor  tympani  muscle  is  not  in  action  it  is 
of  use  in  preventing  the  drum-head  from  being  pushed  out  too 
far.  Wher\  it  contracts  the  membrane  becomes  more  tense.  It 
has  been  supposed 3  to  act  either  as  a  damper,  lessening  the  vi- 
bration of  the  drum-head  in  the  case  of  two  powerful  sounds,  or 
as  having  an  accommodative  power  in  attuning  the  membrane 
to  sounds  which  fall  upon  it.  According  to  Hensen,4  this  action 

1  For  a  good  digest  of  these  see  Hensen's  article  in  Hermann,  loc.  cit. ,  p.  47  et  seq. 

2  Die  Tonenpfindungen,  loc.  cit.  *  Foster,  loc.  cit.  4  Loc.  cit.,  p.  65. 


FUNCTIONS    OF   STAPEDIUS.  257 

is  excited  in  a  reflex  way  by  the  vibrations  of  the  drum-head. 
The  contraction  of  the  tensor  tympani  is  produced  at  will  by 
some  persons,  and  is  accompanied  by  a  crackling  sound. 


Stapedius  Muscle. 

The  stapedius  muscle  is  supposed  to  regulate  the  movements 
of  the  stapes,  by  preventing  its  foot-plate  from  being  forced  in 
upon  the  fenestra  ovalis,  during  great  or  sudden  movements  of 
the  drum-head. 

Lucae,  quoted  by  Hensen,1  found  this  contracted  when  the 
orbicularis  palpebrarum  muscle  was  strongly  excited.  He  found 
with  this  a  weakening  of  the  power  of  hearing  all  musical  notes, 
but  an  increase  in  the  capacity  of  hearing  those  of  10,000  and 
more  vibrations. 

Hensen,  in  one  experiment  carried  a  needle  through  the  ten- 
don of  the  stapedius  muscle.  The  point  of  the  needle  was  in  the 
facial  nerve.  As  long  as  the  tensor  tympani  was  intact,  the 
stapedius  contracted  energetically  upon  the  reception  of  all 
tones,  as  Hensen  believes  in  consequence  of  a  mechanical  move- 
ment of  the  ossicle  produced  by  the  tensor.  When  the  tendon 
of  the  tensor  was  divided,  the  needle  in  the  stapedius  moved 
only  upon  the  production  of  higher  tones,  from  about  7000  vi- 
brations and  upward.  In  lower  tones,  the  movements  were  in- 
distinct, and  the  tones  of  the  great  and  contra  octaves  did  not 
produce  any  effect  at  all. 

Budge,  quoted  by  Hensen,  has  attempted  to  show  that  the 
stapedius  muscle  is  of  importance  in  maintaining  the  equilib- 
rium of  the  body. 

Eustachian  Tube. 

This  passage  serves  to  maintain  an  equilibrium  of  pressure 
between  the  external  air  and  the  tympanum,  and  as  a  means  of 
exit  of  the  secretions  of  that  cavity.  The  physiology  of  the 
Eustachian  tube  has  been  most  accurately  studied  by  Toyiibee 
and  Politzer.  It  is  to  their  studies  and  experiments,  that  we  are 
indebted  for  that  most  valuable  means  of  treatment,  Politzer's 
method  of  inflating  the  middle  ear.  Politzer2  concludes  that — 

1.  The  tube  is  not  constantly  open.  Its  permeability  varies 
in  different  persons.  In  some  cases,  even  in  quiet  respiration, 
an  interchange  of  air  from  the  pharynx  toward  the  tympanum 

1  Loc.  cit.,  p.  65.  s  Lehrbuch,  original,  p.  77. 

17 


258  FUNCTIONS   OF   EUSTACIIIAN   TUBE. 

takes  place ;  'in  others  the  act  of  swallowing  or  a  powerful  ex- 
piration becomes  necessary. 

2.  The  tube  is  especially  opened  by  the  action  of  the  muscles, 
during  the  action  of  swallowing,  as  shown  by  Toynbee  and 
Politzer. 

3.  A  difference  in  the  pressure  of  the  air,  is  more  easily 
•equalized  from  the  tympanum  to  the  pharynx,  than  from  the 
pharynx  to  the  tympanum. 


CHAPTER  X. 

INJURIES  OF  THE  MEMBRANA  TYMPANI. 

Diseases  of  the  Membrana  Tympani  not  Independent  Affections. — Vascular,  Nervous, 
and  Lymphatic  Supply,  a  Part  of  that  of  the  Canal  and  Middle  Ear. — Drum -head 
Subject  to  Injury  by  Explosions,  Blows,  and  so  forth. — Effects  of  Condensed  Air. — 
Serious  Injuries  of  the  Head. — Fracture  of  the  Handle  of  the  Malleus. 

THE  diseases  of  the  membrana  tympani  occur  either  as  a  result 
of  an  inflammation  of  the  external  auditory  canal,  or  of  the 
middle  ear.  I  have  not  seen  any  cases  of  independent  or  primary 
myringitis,  or  inflammation  of  the  drum  membrane,  such  as  are 
delineated  with  theoretical  minuteness  by  some  writers  on  otol- 
ogy. The  anatomical  structure  of  a  membrane  that  has  but  one 
layer  of  tissue  peculiar  to  itself,  and  that  in  its  centre,  but  which 
is  a  direct  uninterrupted  continuation  of  the  adjacent  parts,  pre- 
cludes the  idea  of  an  inflammation  that  occurs  primarily  in  this 
part.  There  is  probably  no  independent  disease  called  myrin- 
gitis, in  the  sense  that  we  speak  of  a  keratitis  or  a  retinitis. 

Dr.  A.  H.  Buck '  has  reported  a  case  of  interlamellar  cyst  of  the  membrana 
tympani,  which  might  be  supposed  to  be  an  independent  disease  of  this  part ; 
but  the  history  shows  that  the  patient  was  suffering,  at  the  time  of  the  formation 
of  the  cyst,  from  chronic  eczema  of  the  auditory  canal,  which  renders  it  probable 
that  the  case  was  one  of  extension  of  disease  of  the  canal  to  the  drum-head. 

The  vascular,  nervous,  and  lymphatic  supplies  of  the  parti- 
tion wall  between  the  auditory  canal  and  the  middle  ear,  belong 
also  to  those  parts  which  it  separates.  Neither  the  integument- 
ary nor  the  mucous  layer  of  the  membrana  tympani  can  be 
fully  separated  from  it.  These  facts  show  that  the  drum-head 
has  no  independent  existence.  In  the  vast  majority  of  instances 
the  diseases  of  the  membrana  tympani  are  of  a  secondary  char- 
acter. It  is  possible,  however,  that  there  may  be  a  primary  in- 
flammation of  the  membrana  tympani  in  exceptional  instances, 
for  example,  from  a  draught  of  air  blowing  upon  the  membrane. 
Yet,  even  in  these  cases,  the  inflammation,  even  if  it  begins  in 
the  drum-head,  advances  so  rapidly  to  the  contiguous  tissue,  that. 


1  Medical  Record,  vol.  vii. ,  p.  572. 


260  INJURIES   OF   MEMBRANA   TYMPANI. 

the  inflammation  becomes  one  of  the  middle  ear  almost  in  an 
instant.  For  these  reasons,  the  term  myringitis  was  discarded 
in  the  earlier  editions  of  this  work,  and  this  example  has  been 
followed  by  most  of  the  recent  writers  on  aural  medicine  and 
surgery.  Sir  William  Wilde,  when  using  the  term  myringitis, 
did  not  mean  an  inflammation  of  the  membrana  tympani  alone, 
but  he  used  it  to  describe  an  inflammation  of  the  middle  ear,  as 
careful  reading  of  his  work  will  show. 

Politzer,  in  his  work  upon  the  ear,  so  recently  translated  into 
English,  describes  a  primary  myringitis,  occurring  "after  the 
action  of  a  cold  wind  upon  the  ear,  after  a  cold  bath,  after  sea- 
bathing, or  in  the  course  of  acute  naso-pharyngeal  catarrhs." 
He  also  describes  the  formation  of  one  or  more  blisters  of  the 
size  of  a  hemp-seed,  and  filled  with  serous  fluid,  as  well  as, 
minute  abscesses.  He  thinks,  however,  that  the  abscesses  of 
the  membrane  described  by  Boeck,  were  secondary  formations, 
occurring  in  the  course  of  acute  or  chronic  affections  of  the 
middle  ear.  After  a  careful  consideration  of  the  views  of  Po- 
litzer, and  my  own  experience,  I  am  still  unconvinced  that  pri- 
mary myringitis  is  anything  more  than  an  extremely  rare  affec- 
tion. If  indeed  it  occurs  at  all,  I  am  doubtful. 

The  membrana  tympani  is,  however,  subject  to  injury  from 
explosions,  or  sudden  and  violent  movements  of  the  atmosphere, 
which  cause  the  undulations  to  be  condensed  and  forced  inward 
upon  the  drum-head.  It  may  also  be  ruptured  by  the  force  of 
condensed  air,  as,  for  example,  that  which  is  found  in  passing 
through  the  lock  of  a  caisson  used  in  excavating  for  the  foun- 
dations of  bridges,  or  the  making  of  tunnels  under  rivers.  The 
membrana  tympani  may  also  be  ruptured  by  blows  or  falls  upon 
the  side  of  the  head  or  upon  the  ear,  or  from  direct  injury  by 
the  striking  of  a  sharp  instrument  directly  upon  the  membrane, 
by  violent  sneezing  or  coughing,  by  the  use  of  appliances  for 
washing  out  the  nostrils,  and  so  forth. 

The  explosion  of  artillery  is  not  apt  to  cause  rupture  of  the 
drum-head.  When  we  consider  the  number  of  persons  who 
have  been  thus  exposed  to  injury,  it  is  somewhat  surprising  that 
no  more  have  suffered  from  this  cause.  After  diligent  inquiry 
among  army  surgeons,  I  have  heard  of  but  very  few  cases  of 
rupture  of  the  membrana  tympani  occurring  from  this  cause  ; 
and  although  I  have  seen  many  patients  who  became  partially 
deaf  from  the  exposures  incident  to  campaigning,  during  our 
late  civil  war,  I  have  as  yet  seen  but  one  case,  where  a  rupture 
of  the  drum  membrane  occurred  from  the  explosion  of  artillery. 
The  long-continued  exposure  to  heavy  firing  often,  and  perhaps 
always,  causes  a  temporary  ringing  in  the  ears,  probably  from 


RUPTURE   OF   MEMBRANA   TYMPANI.  261 

•concussion  of  the  labyrinth,  and  sometimes  hemorrhage  from 
the  vessels  of  the  membrana  tympani,  but  very  rarely  is  a  rup- 
ture produced.  The  effects  of  the  concussion  do  not  always  pass 
away,  and  some  soldiers  acquire  a  chronic  inflammation  of  the 
internal  and  middle  ears  from  this  cause,  just  as  do  boiler- 
makers,  who  work  amid  deafening  noises.  Ruptures  from  con- 
cussion do  occur,  however.  I  once  saw  a  woman  at  the  New 
York  Eye  and  Ear  Infirmary,  who  had  suffered  such  an  acci- 
dent from  the  firing  of  a  pistol  near  her  ear ;  and  Dr.  Hackley 
observed  a  similar  result  in  an  actor  who  was  obliged  to  fire  a 
pistol  over  his  shoulder  during  a  play.  The  power  of  the  mus- 
cles of  the  Eustachian  tube,  which  act  very  quickly,  and  force, 
as  it  were,  a  current  of  air  in  upon  the  drum  membrane  from 
the  inner  side,  is  probably  that  which  counterbalances  the  effect 
of  a  sudden  condensation  of  air  upon  the  outer  side.  The  little 
chink,  which  normally  exists  in  the  calibre  of  the  tube,  is  also  a 
source  of  protection.  Besides  this,  the  structure  of  Shrapnell's 
membrane,  made  up  as  it  is  of  fibres,  much  more  loosely  woven 
together  than  those  of  the  remainder  of  the  drum-head,  assists 
it  to  yield  to  great  shocks  of  sound.  Those  persons  who  suffer 
a  rupture  of  the  drum-head  from  external  concussions,  prob- 
ably have  some  catarrhal  affection  which  prevents  the  air  from 
freely  circulating  in  the  tubes  and  the  cavity  of  the  tympanum  ; 
for  we  can  scarcely  believe  that  so  few  would  suffer  this  acci- 
dent, were  all  drum  membranes  equally  liable  to  it.  During  the 
heavy  fighting  of  our  civil  war,  infantry  soldiers  in  the  trenches 
were  in  the  habit  of  lying  down,  while  the  artillery  behind  fired 
over  their  heads  ;  and  yet,  as  I  have  found  by  inquiry,  rupture 
of  the  membrana  tympani  was  scarcely  heard  of. 

Gruber's  experiments  on  the  cadaver  show  that  the  resisting 
power  of  the  membrane  is  very  great.  Dr.  Schmidekam  as- 
sisted Professor  Gruber1  in  these  experiments,  which  proved, 
according  to  the  former  author,  that  the  resisting  power  of  the 
membrane  was  greater  in  man  than  in  the  other  animals.  It 
required  a  column  of  quicksilver  of  143  ctm.  high  to  rupture  the 
membrana  tympani  of  an  ear  that  had  lain  in  alcohol  for  a  few 
weeks.  The  stapes  and  incus  had  been  removed.  The  rupture 
was  straight  and  parallel  to  the  lower  three-fourths  of  the  ante- 
rior line  of  attachment  of  the  malleus.  In  another  case  a  drum- 
head, which  exhibited  the  remains  of  a  former  inflammatory 
process,  in  the  form  of  a  false  membrane,  was  not  ruptured 
until  a  column  of  quicksilver,  168  ctm.  high,  was  used.  Here 
again  the  rupture  occurred  on  the  anterior  segment. 

1  Lehrbuch,  p.  332. 


262  RUPTURE  OF  MEMBRANA  TYMPANI. 

Gruber  also  examined  the  resisting  power  of  the  drum-head 
by  the  following  experiment :  He  introduced  a  catheter  with  a 
bulbous  extremity  into  the  Eustachian  tube  of  a  fresh  subject, 
having  a  healthy  membrana  tympani,  and  fastened  the  catheter 
in  the  tube  by  means  of  a  stout  thread  stuck  through  it.  He 
then  allowed  a  stream  of  air  from  a  compression  pump — air  that 
had  been  condensed  four  or  five  fold — to  pass  suddenly  into  the 
tube,  or  after  closing  the  tube  by  tying  a  cord  about  it,  he 
stopped  the  external  auditory  canal  by  means  of  a  gutta-percha 
plug,  with  a  small  tube  in  it,  through  which  he  allowed  the 
compressed  air  to  pass.  Gruber  was  never  able  to  break  the 
membrane  in  this  experiment.  The  gutta-percha  plug  with 
the  tube  was  driven  out  of  the  canal,  but  the  membrane  was 
never  ruptured. 

Professor  Gruber  saw  a  great  many  patients  who  were  en- 
gaged in  the  battles  of  Schleswig-Holstein  and  Bohemia  in  1864 
and  1866,  and  although  he  examined  nearly  all  the  aural  patients 
of  the  Garrison  Hospital  in  Vienna,  he  saw  but  one  where  the 
explosion  of  projectiles  had  caused  a  rupture  of  the  drum-head. 
In  this  case  the  soldier  was  knocked  senseless  by  the  explosion 
of  a  grenade,  which  killed  two  near  him.  When  he  recovered 
his  senses  he  was  suffering  from  tinnitus  aurium  in  the  left  ear, 
and  was  deaf  on  this  side.  Pain  occurred,  and  in  three  weeks 
after,  when  he  was  seen  by  Dr.  Gruber,  he  was  found  to  have  a 
roundish  opening  about  one  and  a  half  line  in  diameter,  in  the 
anterior  and  inferior  segment  of  the  drum-head.  The  tubes  were 
pervious,  and  there  was  no  evidence  that  he  had  previously  suf- 
fered from  aural  disease.  This,  however,  was  the  only  case 
among  hundreds  of  soldiers  that  fought  at  Konigsgratz,  who  had 
suffered  the  injury  which  has  been  detailed. 

Dr.  Andrew  H.  Smith,  one  of  my  colleagues  at  the  Man- 
hattan Eye  and  Ear  Hospital,  was  the  medical  officer  in  charge 
of  the  men  engaged  in  laying  the  foundations  for  the  bridge 
from  New  York  to  Brooklyn  over  the  East  River,  and  had  many 
opportunities  of  observing  the  effects  of  compressed  air  upon  the 
membrana  tympani.  Through  Dr.  Smith's  courtesy,  I  saw  some 
cases  that  illustrate  this  subject ;  and  I  here  give  from  Dr.  Smith's 
notes,  one  of  rupture  of  the  membrana  tympani  which  occurred 
while  the  patient  was  passing  through  "the  lock." 

Dr.  Smith  describes  the  case  of  rupture  of  the  membrane  as 
follows : 

John  H ,  on  May  17th,  the  pressure  being  about  35  pounds  to  the  square 

inch  above  the  normal ;  the  patient  was  attacked  while  in  the  lock  going  down 
for  the  first  time,  by  a  severe  pain  in  the  right  ear,  followed  by  a  slight  discharge 
from  the  meatus.  No  sensation  was  felt  as  of  anything  giving  way  in  the  ear. 


EFFECTS   OF    CONDENSED   AIR.  263 

He  completed  bis  watch,  and  then  reported  to  me.  On  examination,  the  drum- 
head was  found  to  be  ruptured  at  its  upper  edge.  The  opening  was  nearly  cir- 
cular and  rather  less  than  a  line  in  diameter.  The  patient  preferred  not  to  go- 
on with  the  work,  and  he  was  not  seen  by  me  again. 

Dr.  Smith  believes  that  most  of  the  men  who  suffered  from 
aural  trouble  after  having  been  in  the  caisson,  had  previously 
some  impairment  of  the  permeability  of  the  Eustachian  tubes. 
The  men  under  his  care  were  "most  strenuously"  instructed  not 
to  enter  the  caisson  unless  they  were  able,  when  holding  the  nose 
and  blowing  forcibly,  to  feel  the  air  enter  both  ears.  Neverthe- 
less, cases  occurred  in  which  this  precaution  was  neglected,  and 
the  individual  was,  in  consequence,  caught  in  the  lock  unable  to 
"  change  his  ears." ' 

Dr.  Smith  says  that  the  structures  within  the  tympanic  cavity 
not  being  acted  upon  by  the  increased  pressure,  "are  placed 
relatively  in  the  same  position  as  the  skin  under  a  cupping-glass," 
by  the  continued  exposure  to  the  effect  of  compressed  air,  when 
the  Eustachian  does  not  open,  or  rather,  as  we  should  say,  when 
it  does  not  act  well,  from  swelling  or  thickening  of  its  tissue. 
Then  the  intense  congestion  occurs,  which  may  be  followed  by 
inflammation,  finally  resulting  in  perforation  of  the  membrane, 
as  happened  in  one  case  reported  by  Dr.  Smith  in  his  paper. 

Politzer's  method  of  inflating  the  ears  was  found  very  useful 
in  treating  these  cases  of  simple  congestion,  which,  if  they  had 
not  been  treated,  would  have  resulted  in  tympanic  inflammation 
and  perforation  of  the  drum-head.  As  an  effect  of  the  use  of 
this  method  of  treatment,  many  of  Dr.  Smith's  men  were  en- 
abled to  continue  at  their  work  who  could  not  have  otherwise 
done  so  without  danger.  The  treatment  became  very  popular 
among  the  men,  so  that  as  many  as  four  or  five  of  them  would 
come  at  Dr.  Smith's  visit  to  have  their  "  ears  blown  out." 

I  saw  three  or  four  of  these  cases  of  congestion  of  the  tym- 
panic cavity,  they  having  been  sent  to  me  by  Dr.  Smith,  and 
was  enabled  to  see  the  great  advantage  of  skilled  medical  advice 
to  these  men.  Many  ears  would  certainly  have  been  perma- 
nently injured  had  not  Politzer's  method  been  employed  at  an 
early  stage  of  the  trouble.2 

1  This  is  the  term  used  by  the  men  to  signify  the  operation  of  holding  the  nose  and 
blowing  until  the  air  is  felt  to  enter  the  middle  ear.     This  operation  has  to  be  con- 
stantly repeated  while  the  air  pressure  is  increasing  in  the  lock,  in  order  to  relieve  the 
pain  resulting  from  the  pressure  upon  the  membrana  tympani.     In  some  persons  the 
act  of  swallowing  answers  equally  well. ' 

2  Dr.  Smith's  paper  on  "The  Effects  of  High  Atmospheric  Pressure,  including  the 
Caisson  Disease,"  received  the  prize  of  the  Alumni  Association  of  the  College  of  Physi- 
cians and  Surgeons  for  1873.     My  extracts  were  taken  from  the  manuscript  loaned  to. 
me  by  the  author. 


264  EFFECTS   OF   CONDENSED   AIR. 

A  gentleman  who  once  consulted  me  in  reference  to  what  I 
deemed  to  be  an  incurable  chronic  catarrh  of  the  middle  ear, 
which  had  resulted  in  thickening  and  sinking  of  the  drum-head, 
afterward  came  to  me  with  a  perforation  of  the  membrane  of 
one  side  and  discharge  of  pus  from  the  tympanum,  which  he 
stated  was  caused  by  a  visit  to  the  caisson.  The  perforation 
soon  healed,  and  the  hearing  was  rather  worse  than  before  the 
accident. 

Dr.  John  Green,1  of  St.  Louis,  had  previously  to  Dr.  Smith 
made  some  observations  upon  "the  physiology  of  the  Eustachian 
tube,  during  a  short  exposure  to  an  atmospheric  pressure  of  sixty 
pounds  to  the  square  inch."  Dr.  Green's  observations  were  made 
while  bridge-piers  were  being  sunk  to  the  rock  underlying  the 
bed  of  the  Mississippi  River  at  St.  Louis  in  1869-70. 

The  entrance  to  the  chamber  of  condensed  air  was  "through 
an  air-lock,  or  small  chamber  into  which  the  condensed  air 
could  be  admitted  gradually,  occupying,  for  the  higher  degrees 
of  pressure,  from  four  to  ten  minutes."  The  exit  occupied  about 
the  same  time. 

The  accidents  to  the  ears  occurred,  as  in  Dr.  Smith's  cases, 
while  passing  through  this  lock.  Sudden  chilling  of  the  body 
from  changes  in  temperature  in  the  chamber  were,  according  to 
Dr.  Green,  causes  of  catarrhs.  This  theory  is  rather  more  suffi- 
cient to  explain  the  cases  of  tympanic  congestion  when  the  tube 
was  not  completely  pervious,  than  the  one  of  mechanical  press- 
ure, although  undoubtedly  both  causes  acted  together  in  pro- 
ducing aural  affections. 

Dr.  Green  notices  an  interesting  phenomenon  observed  in 
coming  out  of  the  lock,  which  Dr.  Smith  also  observed.  There 
was  a  spontaneous  escape  of  air  through  the  Eustachian  tubes 
in  a  succession  of  puffs,  succeeding  each  other  at  intervals  of 
fifteen  or  twenty  seconds,  independently  of  respiration,  and  ab- 
solutely without  the  concurrence  of  an}r  muscular  action.  The 
phenomenon  suggested  to  Dr.  Green  "the  action  of  a  lightly 
resisting  valve,  necessitating  a  slight  but  perceptive  increase  of 
pressure  within  the  tympanic  cavity,  to  open  the  passage  to  the 
pharynx."  Dr.  Green  observed  several  cases  of  rupture  of  the 
drum-head  and  acute  catarrh  occurring  as  a  result  of  the  unequal 
pressure,  and  of  the  exposure  to  an  uneven  temperature. 

Dr.  A.  Magnus,"  of  Konigsberg,  investigated  very  carefully 
the  behavior  of  the  ear  in  condensed  air,  in  1863,  while  a  rail- 
way bridge  was  building  in  his  city.  He  proved  that  the  injury 

1  Transactions  of  the  American  Otological  Society,  1870. 
s  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  270. 


EFFECTS   OF   CONDENSED   AIR.  265 

to  the  ear  was  caused  by  pressure  upon  the  membrana  tympani, 
because  when  he  plugged  the  auditory  canal  hermetically,  no 
unpleasant  sensations  were  felt,  but  when  he  removed  the  stop- 
per the  air  streamed  with  a  powerful  current  into  the  canal,  and 
pain  occurred  very  soon.  The  ear  that  was  stopped  remained 
without  pain,  and  the  Valsalvian  experiment  soon  relieved  the 
pain  in  the  uncovered  one.  Magnus  also  proved  by  an  exam- 
ination of  ears  when  the  pressure  was  being  exerted,  that  the 
membrana  tympani  was  actually  pressed  inward.  The  triangu- 
lar spot  was  obliterated  when  the  pressure  was  greatest  and  the 
pain  severe.  A  patient  without  any  membrana  tympani,  who 
was  subjected  to  the  condensed  air,  had  no  pain.  Indeed,  there 
was  not  a  trace  of  an  unpleasant  sensation. 

The  membrana  tympani  undoubtedly  owes  much  of  its  re- 
sisting power,  as  Mr.  Shrapnell  pointed  out,  to  the  existence  of 
a  triangular  membrane  at  its  upper  portion  that  is  less  tense 
and  thick  than  the  remainder  of  its  structure,  the  so-called  mem- 
brana flaccida,  or  ShrapnelKs  membrane,  which  yields  when 
undue  pressure  is  brought  upon  it.  The  membrane  has,  per- 
haps, some  additional  defence  in  its  oblique  position  in  the 
canal,  which  causes  a  portion  of  it  to  be  covered  by  the  walls  in 
such  a  way  as  not  to  receive  the  whole  force  of  the  column  of 
compressed  air. ' 

The  membrana  tympani  is  perhaps  more  frequently  injured 
by  mechanical  violence  to  the  head  or  to  the  membrane  itself. 
Professor  Robert  F.  Weir,2  formerly  surgeon  to  the  New  York 
Eye  and  Ear  Infirmary,  has  seen  four  such  cases.  In  one  the 
drum-head  was  ruptured  by  a  blow  upon  the  head  with  the  hand. 
In  another,  fragments  of  rock  from  a  blast  struck  the  head  and 
ruptured  the  membrane.  In  the  third  case  the  injury  was  caused 
by  a  snow-ball  striking  the  ear ;  and  in  the  fourth  a  hair-pin  was 
accidentally  forced  through  the  part.  In  the  first  three  of  Dr. 
Weir's  cases  the  rupture  was  slit-shaped,  parallel  and  posterior 
to  the  handle  of  the  malleus. 

I  have  now  under  my  observation  a  gentleman  of  about  fifty 
years  of  age,  whose  membrana  tympani  is  said  to  have  been 
ruptured  when  he  was  a  small  boy,  by  blows  upon  the  side  of 
his  head,  given  by  one  of  his  teachers.  The  membrane  is  nearly 
entirely  gone,  and  there  is  at  times  a  purulent  discharge  from 
the  tympanic  cavity.  Teachers  and  parents  who  have  the  bad 
habit  of  striking  children  unexpectedly  to  their  little  charges, 

1  The  effects  of  compressed  air  upon  the  hearing  power  will  be  again  alluded  to  iii 
the  chapter  on  "Chronic  Non-suppurative  Inflammation." 
*  Verbal  communication. 


266  INJURIES   OF   MEMBRANA  TYMPANI. 

should  be  warned  of  the  danger  of  a  box  on  the  ear  to  the  in- 
tegrity of  the  organ. 

The  membrana  tympani  is  sometimes  ruptured  in  attempts 
to  remove  foreign  bodies,  such  as  inspissated  cerumen,  and  so- 
on, by  means  of  a  probe,  as  has  been  seen  in  one  of  the  preced- 
ing chapters.  The  text-books  of  Toynbee  and  Von  Troltsch 
record  several  interesting  cases  of  injury  to  the  drum-head  by 
mechanical  violence.  The  latter  author  relates  one  in  which  a 
young  man,  while  going  up  a  ladder,  accidentally  struck  his  ear 
against  a  blade  of  straw,  which  passed  through  the  membrane 
and  caused  the  severest  pain,  so  that  he  nearly  fainted.  In  one 
of  Toynbee's '  cases  the  rupture  was  caused  by  an  unexpected 
blow  upon  the  ear  of  a  boy  by  a  tutor.  In  another  case  the  ear 
was  hit  by  a  bolster  while  the  boys  were  engaged  in  a  playful 
contest.  In  both  of  these  cases  the  rent  was  found  to  be  on  the 
lower  part  of  the  membrane. 

Toynbee  also  relates  a  case  which  is  of  interest  on  account 
of  the  nervous  symptoms  produced  by  it.  A  young  man  of 
seventeen,  while  shooting,  in  endeavoring  to  force  his  way 
through  a  hedge,  got  a  twig  into  the  right  auditory  canal.  It 
produced  sudden  and  severe  pain,  followed  by  bleeding.  Mr. 
Toynbee  saw  the  patient  a  week  afterward.  The  pain  speedily 
subsided  ;  but  for  days  after  the  accident  there  was  "a  feeling 
on  the  same  side  of  the  tongue  as  if  something  cold  had  been 
rubbed  over  it ;  the  taste  on  that  side  also  was  impaired."  The 
sensibility  of  the  tongue  to  touch  was,  however,  unimpaired. 

The  chorda  tympani  nerve  was  probably  injured  in  this  case  ; 
for  the  same  sensations  are  sometimes  caused  when  a  bit  of 
cotton-wool  is  brought  in  contact  with  the  cavity  of  the  tympa- 
num and  with  the  nerve. 

I  lately  saw  a  man  of  thirty-eight  years  of  age,  who  stated 
that  at  sixteen,  he  ruptured  the  right  drum-head  in  the  following 
manner  :  While  in  the  woods  engaged  in  securing  sap  for  mak- 
ing maple  sugar,  he  bent  down  over  some  underbrush,  so  that 
a  twig  entered  the  auditory  canal.  Immediately  "he  felt  as 
if  half  his  tongue  were  paralyzed."  He  does  not  remember 
whether  the  ear  bled  or  not,  whether  there  was  any  pain  or 
suppuration  from  it,  but  he  does  remember  the  loss  of  sensation 
in  half  his  tongue.  He  has  never  heard  with  the  ear  since  the 
accident.  He  has  chronic  inflammation  of  the  left  ear.  There 
is  no  aerial  conduction  whatever  on  the  right  side.  There  is  a 
distinct  opacity  in  front  of  the  handle  of  the  malleus. 

This  patient  is  a  highly  educated  man.     While  there  are  sev- 


1  Text-book,  p.  28. 


RUPTURE   OF   MEMBRANA   TYMPANI.  267 

eral  negative  points  in. the  history,  since  he  cannot  remember 
whether  he  had  pain,  or  bleeding,  or  suppuration  from  the  ear, 
there  is  enough  that  is  positive  in  the  history  and  in  the  appear- 
ances to  enable  us  to  believe  that  this  is  a  case  of  rupture  of  the 
membrane,  followed  by  proliferous  inflammation  of  the  tym- 
panum. Since  the  patient  has  a  chronic  inflammation  of  the 
middle  ear  of  the  uninjured  side,  we  may  believe  that  we  can- 
not ascribe  all  the  morbid  changes  in  the  tympanum  to  the  in- 
jury of  the  drum-head,  unless  we  suppose  that  there  may  be  a 
sympathetic  inflammation  of  the  middle  ear,  just  as  there  is  a 
sympathetic  inflammation  of  the  uveal  tract  of  the  eye.  This 
supposition  is  not  wholly  groundless,  although  as  yet  appar- 
ently having  only  an  analogical  foundation.  Sympathetic  in- 
flammation of  the  eye  usually,  if  not  always,  has  its  origin  in 
the  uveal  tract,  and  involves  the  muscle  of  accommodation ; 
why  may  not  a  traumatic  inflammation  of  one  ear,  especially 
an  injury  of  the  ossicles  and  middle  ear,  produce  a  sympathetic, 
plastic  inflammation  of  its  fellow  ? 

The  case  is  inserted  here,  chiefly  to  show  the  effect  of  an  in- 
jury to  the  chorda  tympani  nerve.  In  thinking  it  over,  how- 
ever, the  possibility  of  a  sympathetic  otitis  has  occurred  to  me. 
Reasoning  from  analogy,  it  is  possible  to  suppose  such  a  condi- 
tion of  things. 

The  function  of  the  chorda  tympani  is  probably  chiefly  in  connection  with 
that  of  taste,  and  not  of  hearing. 

Professor  Flint '  relates  a  case  which  sustains  this  view.  A  soldier  received 
a  gunshot  wound,  the  ball  passing  through  the  head,  entering  just  above  the  ala 
of  the  nose,  on  the  left  side,  and  emerging  behind  the  mastoid  process  of  the 
right  temporal  bone.  The  wound  healed,  with  the  iisual  symptoms  of  complete 
facial  paralysis  on  the  right  side.  The  buccinator  and  orbicularis  oculi  were 
completely  paralyzed.  The  hearing  was  perfect.  The  sense  of  taste  was  entirely 
abolished  in  the  anterior  portion  of  the  tongue  on  the  right  side.  These  facts 
were  verified  by  Professor  Dalton,  of  this  city. 

Experiments  upon  dogs  and  cats,  and  other  animals,  also  show,  according  to 
Flint,  that  the  chorda  tympani  influences  taste ;  for  sections  of  the  root  of  the 
fifth  pair,  or  of  the  chorda  tympani,  is  followed  by  loss  of  taste  in  the  anterior 
portion  of  the  tongue. 

The  chorda  tympani  is  given  off  from  the  facial,  as  it  passes  vertically  down- 
ward at  the  back  of  the  tympanum,  about  a  quarter  of  an  inch  before  its  exit 
from  the  stylo-mastoid  foramen.  It  ascends* from  below  upward  in  a  distinct 
canal,  parallel  with  the  aquseduct  of  Fallopius,  and  enters  the  cavity  of  the  tym- 
panum through  an  opening  between  the  base  of  the  pyramid  and  the  attachment 
of  the  membrana  tympani.  It  becomes  covered  by  mucous  membrane,  and 
passes  forward  through  the  tympanic  cavity  between  the  handle  of  the  malleus 
and  the  vertical  cms  of  the  incus  (see  Fig.  44,  on  p.  194),  and  then  passes  out 


1  The  Physiology  of  Man,  The  Nervous  System,  p.  157. 


268  RUPTURE   OF   MEMBRANA   TYMPANI. 

of  the  cavity,  through  the  canal  of  Hugier,  at  the  inner  side  of  the  Glaserian 
fissure.  It  then  passes  downward,  between  the  two  pterygoid  muscles,  and 
meets  the  gustatory  nerve  at  an  acute  angle,  and  communicating  with  this  it 
passes  to  the  submaxillary  gland ;  after  joining  the  sub  maxillary  ganglion  it  ter- 
minates in  the  lingualis  muscle. 

Its  anatomy  seems  to  indicate  that  it  has  very  little  to  do  with  the  function 
of  hearing.  It  merely  passes  through  the  tympanum,  without  supplying  any  of 
its  tissues,  as  has  already  been  described  in  the  chapter  on  the  anatomy  of  the 
middle  ear. 

Claude  Bernard  also  performed  experiments  upon  the  chorda  tympani  of  cats 
and  Albino  rats,  by  cutting  out  the  facial  nerve  at  its  exit  from  the  stylo-mastoid 
foramen.  In  from  six  to  ten  days  the  terminal  twigs  of  the  lingualis  nerve,  and 
the  nerve-fibres  coming  from  the  chorda  tympani  were  found  to  have  undergone 
fatty  degeneration.  Degenerated  nerve-fibres  were  also  found  in  the  tip  of  the 
tongue,  but  not  in  the  papillae.  There  were  also  degenerated  nerve-fibres  in  the 
submucous  tissue.1 

Severe  vomiting  sometimes  causes  a  rupture  of  the  drum- 
head, as  does  strangulation  by  hanging.  The  cases  of  rupture 
that  occur  during  whooping-cough,  and  sneezing  or  blowing  the 
nose,  are  not  properly  to  be  considered  in  the  present  chapter ; 
for  when  the  membrana  tympani  is  ruptured  in  such  cases, 
there  is  usually,  if  not  always,  some  pre-existing  catarrh  of  the 
Eustachian  tube  and  tympanic  cavity.  I  have  seen  several  such 
cases,  but  in  all  of  them  I  have  been  able  to  trace  disease  of  the 
middle  ear  as  having  preceded  the  breaking  of  the  drum-head. 
The  great  accumulation  of  mucus  caused  by  the  catarrhal  in- 
flammation will  be  very  apt  to  cause  a  rupture  by  mechanical 
pressure  from  within  upon  a  distended  mucous  membrane  and 
fibrous  layer,  unless  the  cavity  be  emptied  by  means  of  the 
catheter  or  Politzers  method. 

In  countries  where  punishment  is  meted  out  in  exact  pro- 
portion to  the  amount  of  personal  injury  done  to  the  person 
assaulted,  blows  upon  the  side  of  the  head  which  result  in  rup- 
ture of  the  membrana  tympani  are  made  the  subject  of  careful 
medico-legal  examination.4 

In  order  to  determine  the  cause  of  a  rupture  of  the  membrana 
tympani,  it  must  be  seen  within  a  few  hours  of  the  injury  ;  for 
suppuration  may  occur  soon  after  it  has  occurred,  when  it  will 
be  impossible  to  decide  whether  it  had  a  traumatic  or  spontane- 
ous origin. 

1  Monatsschrift  f iir  Ohrenheilkunde,  No.  1,  1873,  from  Comptes  Rendus,  Hebdom. 
dea  Seances  de  1'Academie  des  Sciences,  T.  Ixxv.,  No.  27.  Paris,  1872. 

s  According  to  the  Austrian  criminal  code,  an  injury  is  defined  to  be  a  severe  one, 
when  the  person  suffering  it  is  deprived  of  his  usual  health,  or  kept  from  his  occupa- 
tion for  a  period  of  not  less  than  twenty  days.  — Politzer,  Wiener  Med.  Wochenschrift, 
Nos.  35,  36,  1872. 


KUPTURE   OF   MEMBKANA   TYMPANI.  269 

A  traumatic  rupture  of  the  membrana  tympani,  especially 
one  arising  from  the  perforation  of  the  membrane  by  a  sharp 
instrument,  is  much  more  apt  to  cicatrize  promptly,  without 
suppuration,  than  one  that  has  been  perforated  in  the  course  of 
inflammation  of  the  middle  ear. 

The  force  of  large  waves  upon  the  side  of  the  head  in  sea- 
bathing, is  an  occasional  cause  of  rupture  of  the  membrana 
tympani.  I  have  seen  such  cases,  and  one  where  both  mem- 
branes were  ruptured.  A  wave  is  sometimes  allowed  to  strike 
upon  the  membrane  with  great  violence,  and  if  it  do  not  break 
it,  it  will  at  least  excite  an  inflammatory  action.  Physicians 
who  practice  at  the  sea-side,  should  warn  their  patients  of  this 
danger  from  surf -bathing.  Long  Branch  and  Newport,  furnish 
every  year  a  certain  contingent  of  aural  patients  from  this  cause. 

A  little  care  so  that  the  waves  do  not  strike  the  side  of  the 
head  in  full  force,  and  plugging  the  meatus  lightly  with  cot- 
ton, will  be  found  to  be  a  sufficient  protection  from  the  sever- 
ity of  the  waves.  If  water  be  allowed  to  stay  in.  the  auditory 
canal  for  some  time,  it  becomes  a  source  of  congestion ;  but 
such  causes  of  diseases  of  the  middle  ear  are  more  appropriately 
considered  in  a  subsequent  chapter. 

Dr.  C.  H.  Burnett,1  of  Philadelphia,  has  reported  a  case  of 
evulsion  of  the  membrana  tympani,  from  the  splashing  of  mud 
into  the  ear  by  a  horse  while  the  patient  was  crossing  the  street. 
The  patient  was  thirty-nine  years  old,  and  consulted  Dr.  Burnett 
three  days  after  the  accident.  He  stated  that  his  ear  was  sound 
until  the  mud  came  into  it.  Upon  returning  to  his  shop — he  was 
a  machinist — he  was  examined  by  some  of  his  comrades,  who 
said  they  saw  foreign  objects  in  the  meatus,  which  they  pro- 
ceeded to  extract  with  chips  and  mechanics'  small  tools.  Several 
"little  white  pebbles"  were  taken  out,  which  were  probably  the 
ossicles.  Great  impairment  of  the  hearing  of  the  ear  followed. 
The  patient  was  very  pale,  anxious  and  bathed  in  cold  perspira- 
tion when  he  visited  Dr.  Burnett.  A  watch  that  should  have 
been  heard  40  feet  was  only  heard  5  ctm.  The  tuiiing-f ork  placed 
on  the  vortex  was  heard  very  distinctly  in  the  injured  ear. 

On  examination,  Dr.  Burnett  found  the  meatus  uninjured.  A 
small  piece  of  mud  was  adherent  to  the  antero-superior  quadrant 
of  the  periphery  of  the  membrana  tympani.  The  membrane  was 
entirely  destroyed,  except  a  very  narrow  border.  There  were  no 
ossicles  visible.  The  inner  wall  of  the  tympanum  was  fully  ex- 
posed to  view.  The  mucous  membrane  was  healthy,  but  slightly 
abraded  on  the  promontory.  Twenty  days  after,  without  treat- 

1  Transactions  of  the  American  Otological  Society,  1872. 


270  RUPTURE  OF  MEMBRANA  TYMPANI. 

ment,  patient  was  free  from  pain  and  "ruddy  and  cheerful." 
The  border  of  the  membrana  tympani  had  become  adherent  to 
the  promontory.  Of  course  the  hearing  power  was  not  improved, 
thanks  to  the  care  of  his  surgical  comrade,  who  so  carefully 
removed  the  "  white  pebbles  "  from  his  ear. 

Dr.  J.  Orne  Green  '  reports  a  case  where  the  explosion  of  a 
bag  of  gas  near  the  ear  caused  a  rupture  of  the  membrana 
tympani.  The  patient,  who  was  preparing  for  an  exhibition  in 
which  an  oxy -hydrogen  light  was  to  be  used,  was  standing  a 
few  feet  from  the  bag,  and  with  his  left  side  toward  it  at  the 
time  of  the  explosion.  The  immediate  effect  was  some  slight 
confusion  of  intellect,  which  soon  passed  off  ;  but  the  next  day 
the  left  ear  began  to  be  painful,  and  on  blowing  the  nose,  air 
whistled  through  it. 

Dr.  Green  saw  the  patient  twelve  days  after  the  accident, 
and  found  the  membrana  tympani  red  and  swollen,  and  on  the 
posterior  segment  just  behind  the  umbo,  a  rupture  1£  line  long, 
nearly  perpendicular,  through  which  purulent  matter  could  be 
forced  by  Valsalva's  method  of  inflation.  H.  D.,  ^. 

Dr.  Green  states  that  this  patient  had  previously  suffered 
from  impaired  hearing  and  mucous  rales  in  his  ears.  Most  of 
the  cases  of  rupture  of  the  drum-head  on  record,  if  the  ante- 
cedents had  been  inquired  into,  would  undoubtedly  exhibit  the 
same  condition  of  things. 

The  assistant  of  the  patient  whose  case  has  just  been  quoted, 
suffered  at  the  same  time  from  the  explosion  of  a  bag  of  gas, 
and  also  received  rupture  of  the  membrane,  which  resulted  in  a 
purulent  inflammation  of  the  tympanic  cavity.  He  was  treated 
by  Dr.  Henry  L.  Shaw,  of  Boston.  In  both  of  these  cases  the 
rupture  healed  perfectly,  and  the  hearing  power  was  partially 
restored.  In  Dr.  Green's  case  it  became  ff- 

Dr.  Green  saw  two  other  cases  in  which  the  patients  suffered 
from  the  concussion  of  the  same  accident.  It  caused  a  loud 
buzzing  in  the  ear  and  confusion  in  the  head.  The  patients 
consulted  Dr.  Green  on  account  of  the  tinnitus  which  was  caused 
in  one  case,  but  aggravated  in  the  other,  for  the  latter  patient 
had  previously  suffered  from  disease  of  the  middle  ear.2 

If  a  person  be  a  sufferer  from  catarrh  of  the  middle  ears,  the 
drum-head,  as  has  been  already  intimated,  is  much  more  likely 
to  be  ruptured  by  blows,  falls,  exposure  to  the  surf  in  bathing, 

1  Transactions  of  the  American  Otological  Society,  1872. 

8  Dr.  Green  records  several  other  cases  of  injury  of  the  side  of  the  head  which  pro- 
duced a  rupture  of  the  membrana  tympani,  but  as  they  do  not  differ  from  others  that 
are  noticed  in  this  chapter,  I  beg  to  refer  my  readers  who  may  wish  to  carry  this  sub- 
ject farther,  to  his  interesting  paper. 


RUPTURE   OF   MEMBRANA   TYMPANI.  271 

or  the  like.  In  fact,  I  am  inclined  to  doubt  if  persons  with  well 
ventilated  tympanic  cavities,  and  normally  acting  drum-heads 
ever  suffer  a  rupture  of  the  membrana  tympani,  except  from 
very  great  direct  violence. 

In  1875  I  saw  a  little  boy  who  was  thrown  from  his  pony  a 
few  hours  before  he  consulted  me.  He  struck  upon  his  right 
side,  and  he  had  a  free  discharge  from  his  right  ear  immediately 
afterward.  His  hearing  distance  was  ¥V  when  examined,  and 
he  heard  the  tuning-fork  better  on  the  injured  side.  Blood  was 
found  on  the  walls  of  the  auditory  canal,  and  the  membrana 
tympani  was  ruptured  in  the  centre.  The  ear  was  let  alone  very 
carefully,  and  the  drum-head  soon  healed.  There  remained, 
however,  a  depression  in  the  centre  at  the  site  of  the  rupture. 
This  little  fellow  had  nasal  and  pharyngeal  catarrh  at  the  time 
he  received  the  fall,  or  I  suppose  it  is  not  likely  that  the  mem- 
brana tympani  would  have  ruptured  from  what  was  a  slight 
injury,  for  he  fell  upon  the  lawn  of  a  country  place,  and  from 
a  very  small  pony.  At  any  rate,  in  spite  of  the  best  of  care  from 
his  family  and  from  a  distinguished  expert  in  aural  disease,  with 
whom  I  have  occasionally  seen  him  professionally,  he  has  gone 
on  with  a  catarrhal  or  proliferous  inflammation  in  the  middle 
ears,  until  now,  as  he  is  growing  into  manhood,  his  hearing  is 
very  much  impaired. 

I  once  saw  a  case  of  hemorrhage  from  the  auditory  canal  in 
a  boy  of  three  and  a  half  years,  who  fell  from  a  rocking-horse. 
He  had  had  a  discharge  from  the  same  ear  a  year  before  which 
had  ceased.  Some  hard  wax  and  a  large  blood-clot  were  re- 
moved from  the  auditory  canal,  but  the  membrana  tympani  was 
uninjured  and  looked  natural. 

In  1881  a  young  gentleman  of  nineteen  consulted  me  in  re- 
gard to  an  injury  to  his  left  ear,  of  which  he  gave  the  following 
account :  Two  days  before  it  was  hit  by  the  flat  surface  of  a 
boxing-glove  in  the  hands  of  his  antagonist.  He  became  dizzy 
and  felt  a  sense  of  pressure  upon  the  ear.  He  did  nothing  to 
relieve  these  symptoms  and  they  passed  away.  But  on  consult- 
ing me,  he  states  that  he  has  now  a  feeling  of  tightness  and 
pain  in  the  ear,  and  noise  causes  discomfort.  He  once  had  a 
discharge  from  the  ear  after  scarlet  fever.  His  hearing  dis- 
tance is  58-g-  on  the  injured  side,  f-f  on  the  other.  The  tuning-fork 
is  heard  better  in  the  affected  ear.  There  is  a  red  line  through 
the  anterior  segment  of  the  membrane,  beginning  at  the  end  of 
the  malleus.  The  ear  was  inflated  by  Politzers  method,  and 
this  was  repeated  every  few  days.  The  patient  was  also  ad- 
vised to  wear  cotton  in  the  meatus  of  that  side.  The  ear  grad- 
ually recovered  its  normal  sensations. 


272  RUPTURE   OF   MEMBRANA   TYMPAXI. 

Here,  again,  we  had  to  do  with  an  ear  that  was  probably  riot 
entirely  sound  when  the  accident  occurred.  It  is  probable,  from 
the  history,  that  the  drum-head  was  at  one  time  injured  by 
ulceration,  and  that  it  was  a  cicatricial  membrane  when  the 
canal  was  struck. 

In  the  following  case  the  drum-head  was  so  badly  injured  by 
direct  violence,  that  it  will  never  be  a  perfect  membrane : 

F.  N ,  aged  forty-one  years.     Five  days  ago  his  infant  child,  while  he  was 

playing  with  it,  pushed  a  button-hook  into  the  right  auditory  canal.  A  momen- 
tary pain  occurred,  attended  by  bleeding.  The  patient's  wife  washed  out  the 
ear,  and  great  pain  followed.  Since  then  the  pain  has  diminished,  and  he  has  a 
purulent  discharge  from  the  ear.  He  never  had  a  disease  of  the  ear  before,  as 
far  as  he  knows.  The  hearing  distance  is  R.  E.,  -43» ;  L.  E.,  $£.  The  tuning-fork 
placed,  on  the  vertex  is  heard  better  in  the  right  ear.  The  bone  conduction  is 
better  than  the  aSrial  on  the  right  side.  The  upper  wall  of  the  osseous  canal  is 
red  and  swelled.  Pus  lies  upon  the  right  drum-head.  It  is  red  in  the  periphery 
and  along  the  handle  of  the  malleus.  It  is  perforate  in  the  inferior  and  the  pos- 
terior quadrant.  The  left  membrana  tympani  is  opaque  and  neoplastic.  The  patient 
was  treated  for  two  months.  The  suppuration  nearly  ceased.  He  had  no  pain, 
and  slight  tinnitus,  when  I  last  saw  him,  but  the  perforation  in  the  drum-head 
remained. 

* 

Although  this  patient  had  no  recollection  of  ever  having  had 
a  disease  of  his  ears,  I  am  sure,  he  must  have  one  day  had  some 
affection  of  his  uninjured  ear.  The  impairment  of  hearing  (f§), 
and  the  neoplastic  drum  membrane  cause  me  to  believe  this. 
He  may  also  have  suffered  in  his  right  ear,  so  that  it  may  have 
been  more  susceptible  to  injury  than  a  normal  drum-head.  Yet 
it  must  be  admitted,  that  a  thrust  with  a  button-hook  is  capable 
.  of  rupturing  a  drum-head  whose  tissue  has  never  been  injured 
by  ulceration. 

At  a  recent  meeting  of  the  New  York  Ophthalmological  So- 
ciety, Dr.  Loring  reported  a  case  of  rupture  of  the  drum-head  on 
each  side,  with  bleeding,  from  a  fall  upon  the  forehead  upon  the 
fender.  The  patient  was  a  child,  and  the  strictest  inquiry,  ac- 
cording to  Dr.  Loring,  failed  to  elicit  the  history  of  catarrh  of 
the  nares  or  middle  ears. 

In  this  case  the  rupture  occurred,  as  Dr.  Loring  thinks,  from 
contre-coup,  the  ears  not  being  directly  affected  by  the.  fall,  but 
the  full  force  came  upon  the  region  of  the  frontal  sinus.  The 
child,  according  to  the  statement  of  Loring,  has  since  suffered 
at  times  from  aural  catarrh. 

Very  severe  injuries  of  the  head,  such  as  those  suffered  by 
laborers  falling  from  scaffoldings  used  in  building,  or  by  being 
hit  by  "falling  planks"  (Buck),  falls,  gun-shot  wounds  in  the 


FRACTURE   OF  TEMPORAL   BONE.  273 

auditory  canal,  serious  beatings  or  pummellings  upon  the  head, 
especially  over  the  temporal  bone,  may  produce  fractures  of  the 
temporal  bone,  as  well  as  other  bones  of  the  skull.  Bleeding 
from  the  ear,  or  a  serous  discharge  from  the  ear,  are  among  the 
prominent  symptoms  of  such  an  injury.  These  cases  are  usu- 
ally seen  by  general  surgeons,  who  do  not  give  the  ear  a  critical 
examination  in  determining  the  nature  and  extent  of  the  in- 
juries. It  was  formerly  supposed1  that  a  severe  and  long-con- 
tinued bleeding  from  the  ear  was  positive  proof  of  a  lesion  of  one 
of  the  sinuses.  But  as  Buck2  has  shown,  a  bleeding  from  the 
tympanic  artery  may  cause  this,  without  necessarily  involving 
the  sinuses.  When  an  injury  to  the  head  is  followed  by  bleed- 
ing from  the  ear,  even  if  it  be  trivial,  we  may,  as  stated  by  Buck, 
diagnosticate  a  fracture  of  the  temporal  bone  in  the  vicinity  of 
ShraprielPs  membrane,  and  probably  in  the  line  of  the  Glaserian 
fissure,  but  we  cannot  state  that  a  deeper  and  a  more  extensive 
injury  has  occurred.  A  fracture  of  the  temporal  bone  may  occur, 
however,  without  hemorrhage  from  the  ear.  Buck  quotes  a  case 
from  Dr.  Geo.  L.  Peabody,  which  proves  this.  A  man  fell  twenty 
feet  from  a  scaffolding,  striking  his  head  upon  the  pavement. 
He  died  two  days  after  the  injury.  There  was  no  evidence  of 
fracture  of  the  bones  of  the  skull.  "  There  was  a  thin  watery 
discharge  from  the  nose,  but  there  were  no  aural  signs  except 
deafness."  There  were  several  fractures  of  the  skull.  There 
was  one  on  the  right  side  extending  from  the  foramen  lacerum 
posterium  through  the  middle  of  the  petrous  portion  of  the  tem- 
poral bone,  and  terminating  in  the  roof  of  the  tympanic  cavity. 
The  ossicles  were  found  imbedded  in  a  clot  of  blood.  There  was 
no  blood  in  the  mastoid  cells.  On  the  other  side,  there  was  a 
more  extensive  fracture  of  the  same  parts  with  a  clot  around  the 
ossicles  and  also  in  the  mastoid  cells.  The  fracture  extended 
into  the  semi-circular  canals  of  both  sides,  and  the  right  cochlea 
contained  a  clot. 

It  is  certain  also,  that  patients  recover  from  fractures  of  the 
tympanic  portion  of  the  temporal  bone.  A  prominent  physician 
of  a  neighboring  city  was  attacked  by  ruffians  one  night,  a  few 
years  since,  and  severely  beaten  over  the  head,  so  that  he  was 
unconscious  for  a  short  time.  A  large  hemorrhage  occurred 
from  one  ear,  but  he  recovered  perfectly,  except  that  his  hearing 
power  was  nearly  destroyed  upon  that  side.  The  membrana 
tympani  a  few  months  after  the  injury  was  without  a  cicatrix 
or  other  evidence  of  a  rupture,  as  I  found  on  examination.3 


1  Prescott  Hewitt  in  Holmes'  Surgery,  vol.  ii.,  p.  128.     Edition  of  1861. 

2  Diseases  of  the  Ear,  p.  278  et  seq.  3  Loc.  cit  ,  p.  29. 

18 


274  HEMORRHAGE  FROM  TYMPANUM. 

This  gentleman  having  died  some  year  or  so  after  the  injury, 
it  was  supposed  by  some  that  his  death  resulted  from  it.  But  I 
have  very  good  authority  for  stating  that  he  died  from  chronic 
renal  disease. 

Dr.  J.  D.  Rushmore,  surgeon  to  the  Brooklyn  Eye  and  Ear  Hos- 
pital, also  reports '  with  great  care  a  case  bearing  on  this  subject. 
A  man  of  sixty-eight  years,  after  a  peculiar  and  uncomfortable 
feeling  in  his  head  for  a  few  minutes,  fell  backward  and  toward 
the  left  side,  and  lost  in  a  few  minutes,  by  the  estimate  of  a  physi- 
cian, about  sixteen  ounces  of  venous  blood  from  his  left  auditory 
canal.  He  became  unconscious  for  a  few  hours,  and  complained 
of  headache  and  vertigo.  The  man  had  been  a  busy  but  well 
man.  There  was  no  renal  disease.  Dr.  Rushmore  saw  the  patient 
four  days  after  the  injury.  There  was  then  tenderness  around 
the  left  auricle  and  dulness  of  hearing  on  that  side.  There  was 
slight  oedema  of  the  mastoid  and  a  narrow  ecchymotic  spot  ex- 
tending toward  the  styloid  process.  The  auricle  was  hyper- 
semic.  A  soft  clot  filled  the  canal,  and  this  was  swollen  and 
tender  after  the  clot  was  removed.  There  was  no  hemorrhage 
and  no  serous  discharge.  Hearing  distance  for  the  watch,  0; 
tuning-fork  better  through  the  bones,  and  it  was  heard  better 
on  the  sound  side.  The  drum-head  could  not  be  seen.  The 
ear  was  treated  by  cleansing,  leeches  to  the  mastoid,  oleate  of 
morphia  in  front  and  behind  the  auricle.  Sleeplessness  was  re- 
lieved by  opium,  bromide  of  potash,  and  alcohol.  The  result 
was  that  the  patient  finally  heard  the  watch  in  contact  with  the 
ear,  and  the  voice  fifteen  feet.  The  bone  conduction  remains  bet- 
ter than  aerial.  In  all  res-pects,  except  the  dulness  of  hearing, 
the  patient,  ten  months  after  the  injury,  was  as  well  as  before  he 
received  it.  When  the  membrana  tympani  was  first  seen,  fully 
six  weeks  after  the  injury,  there  was  a  red  irregular  line,  broad 
on  the  periphery,  and  narrowing  toward  the  centre  of  the  mem- 
brane, extending  from  the  apex  of  the  light  spot  to  the  end  of 
the  handle  of  the  malleus.  Five  days  after,  the  red  line  had 
nearly  disappeared,  and  the  light  spot  began  to  be  mapped  out. 
There  was  a  purulent  discharge  from  the  ear  for  sixteen  days 
after  the  injury. 

Dr.  Rushmore  concludes,  that  there  was  a  fracture  beginning 
in  the  external  auditory  canal,  and  extending,  down  ward  and 
forward.  The  origin  of  the  bleeding  he  is  at  a  loss  to  explain. 
I  think  there  is  no  reasonable  doubt,  however,  that  it  was  from 
the  vessels  of  the  tympanic  cavity. 

The  tuning-fork  located  the  situation  of  the  hemorrhage. 

1  Archives  of  Otology,  vol.  ix 


HEMORRHAGE  FROM  TYMPANUM.  275 

Had  there  been  a  hemorrhage  into  the  labyrinth,  the  bone 
conduction  would  not  have  been  better  than  the  aerial.  A 
careful  examination  of  an  osseous  specimen  will  convince  any 
one  of  the  possibility  of  rupturing  the  tympanic  vessels  only, 
by  such  a  fall.  The  healing  of  the  membrana  tympani  with 
scarcely  a  trace  of  the  rupture,  explains  those  cases  of  re- 
ported bleeding  from  the  ear,  when  the  drum-head  shows  no 
cicatrix  in  a  few  weeks  after.  That  such  a  perfect  healing  may 
occur,  I  have  been  able  to  demonstrate  on  several  cases. 

A  profuse  watery  discharge  from  the  ear,  occurring  immedi- 
ately after  the  injury,  is  good  evidence  of  a  fracture  of  the  pe- 
trous portion  of  the  temporal  bone,  but  a  watery  discharge  may 
set  in  a  short  time  after  the  accident,  and  be  merely  inflamma- 
tory in  character  and  by  no  means  be  the  cerebro-spinal  fluid, 
even  though  it  be  excessive.  The  facial  canal  and  the  motor 
filaments  of  the  fifth  nerve  may  be  injured  in  fracture  of  the 
temporal  bone,  and  paralysis  occur. 

Our  knowledge  of  these  cases  would  be  greatly  increased,  if 
a  careful  examination  of  the  membrana  tympani  were  made  in 
each  case  of  supposed  fracture  of  the  base  of  the  skull. 

Prognosis. — The  prognosis  of  a  fracture  of  the  temporal  bone 
with  rupture  of  the  membrana  tympani  is  by  no  means  unfavor- 
able, except  as  regards  an  impairment  of  the  hearing,  as  is  seen 
by  the  illustrative  cases.  But  each  case  must  be  considered  by 
itself.  No  general  prognosis  can  be  made. 

The  prognosis  in  a  case  of  rupture  of  the  membrana  tympani 
depends  very  much  upon  the  nature  of  the  injury  that  caused  it. 
An  accident  of  this  kind,  when  produced  by  the  concussion  of  a 
heavy  explosion  or  of  a  severe  blow  upon  the  side  of  the  head, 
is  much  more  serious  in  its  nature  than  an  injury  to  a  drum- 
head from  the  forcing  through  it  of  any  sharp  body,  such  as  a 
knitting-needle,  pen-holder,  twig  of  a  tree,  a  blade  of  straw,  or 
the  like.  The  former  class  of  injuries  are  apt  to  produce  a  frac- 
ture of  the  temporal  bone,  a  concussion  of  the  labyrinth,  or  a 
fracture  or  dislocation  of  the  ossicula,  as  well  as  a  rupture  of 
the  drum-head.  Such  a  result,  at  once  takes  the  affection  away 
from  the  category  of  simple  injuries,  and  renders  it  a  very  seri- 
ous one,  not  only  with  reference  to  the  hearing  power,  but  also 
as  regards  life.  The  tuning-fork  becomes  a  valuable  assistant 
to  diagnosis  in  cases  of  rupture.  Its  vibrations  will  be  heard 
more  distinctly  in  the  injured  ear  than  the  other,  and  the  bone 
conduction  will  be  better  than  the  aerial,  if  the  labyrinth  be  not 
injured.  A  simple  rupture  usually  heals  in  a  few  days  without 
great  injury  to  the  hearing.  A  suppurative  process  may  result, 


276  RUPTURE   OF   MEMBRANA   TYMPANI. 

however,  and  become  chronic,  when  the  treatment  should  be 
the  same  as  that  of  any  other  similar  affection  arising  spon- 
taneously. 

Treatment. — We  can  do  very  little  indeed  in  the  way  of 
treatment,  if  no  inflammatory  symptoms,  such  as  pain  or  swell- 
ing, occur.  Above  all,  we  should  not  disturb  the  ear  imme- 
diately after  the  occurrence  of  the  injury,  as  is  sometimes 
mistakenly  done,  by  syringing  it.  There  is  a  very  prevalent 
disposition  in  the  profession,  to  syringe  the  ear  in  every  case  of 
aural  disease  that  presents  itself  ;  but  no  ear  should  be  syringed 
without  a  good  and  sufficient  reason. 

A  large  clot  in  the  canal  should  be  removed  with  gentleness 
and  care,  but  syringing  the  ear  immediately  after  a  minute 
hemorrhage  from  a  superficial  injury  is  bad  practice.  Union 
by  first  intention,  is  favored  by  letting  the  drum-head  absolutely 
alone.  It  is  meddlesome  surgery  to  do  very  much  to  such  cases. 

When  inflammatory  symptoms  occur,  they  should  be  met  by 
leeches,  the  warm  douche,  and  by  the  other  means  that  will  be 
detailed  in  the  chapters  on  "Acute  Inflammation  of  the  Middle 
Ear."  Meanwhile  the  ear  should  be  protected  from  the  cold  air 
by  a  bit  of  cotton  placed  in  the  meatus,  and  the  patient  should 
be  kept  under  careful  but  not  meddlesome  observation. 


Fracture  of  the  Handle  of  the  Malleus. 

This  rare  accident  has  been  described  by  Meniere,  Von 
Troltsch,  and  Weir.1  The  history  of  the  case  of  the  second- 
named  author  is  as  follows  :  A  man  accidentally  thrust  a  pen- 
handle  which  he  held  in  his  hand  into  his  ear,  in  consequence 
of  knocking  his  elbow  against  a  door.  The  severe  pain  caused 
him  to  faint.  After  he  recovered,  he  found  that  he  heard  badly 
from  the  injured  ear,  and  he  suffered  from  tinnitus  of  that  side. 
Von  Troltsch  saw  the  case  a  year  after,  and  from  the  peculiar 
slanting  position  of  the  handle  of  the  malleus,  and  from  the  fact 
that  it  was  uncommonly  thick  under  the  short  process,  he  diag- 
nosticated a  united  fracture  of  the  manubrium. 

Hyrtl,  is  quoted  by  Von  Troltsch,  as  having  described  such  an 
united  fracture  in  the  malleus  of  a  prairie  dog.  This  fracture 
was  also  situated  just  under  the  neck  of  the  malleus.  The  mem- 
brana  tympani  of  this  animal  is,  according  to  Hyrtl,  very  super- 
ficially situated. 

1  Von  Troltsch  on  the  Ear,  second  American  edition,  p.  151. 


FKACTUKE  OF  HANDLE  OF  MALLEUS.  277 

Dr.  Weir's  case  is  one  of.  ununited  fracture. '  A  man,  aged 
thirty-two,  came  to  Dr.  Weir's  clinic,  at  the  New  York  Eye 
and  Ear  Infirmary,  on  May  11,  1867,  and  gave  the  following 
history  :  Four  months  previously  he  fell  into  an  open  area-way, 
a  distance  of  about  fifteen  feet.  He  became  unconscious,  and 
remained  so  for  nearly  sixteen  hours.  He  had  been  informed 
that  his  right  ear  bled  for  about  an  hour.  Upon  returning  to 
consciousness  he  felt  a  severe  pain  from  the  right  ear,  across 
the  forehead  to  the  other  ear.  The  pain  lasted  for  nearly  a 
month,  and  gradually  diminished ;  but  the  great  tinnitus,  which 
dated  from  the  time  of  the  injury,  continued  unabated.  There 
was  no  history  of  any  foreign  body  having  entered  the  ear.  The 
watch  was  heard  upon  the  affected  side  when  pressed  firmly 
upon  the  ear. 

The  drum  membrane  was  normal  in  color  ;  but  there  was  an 
irregularity  in  the  handle  of  the  malleus.  The  bone  was  found 


FIG.  79.  FIG.  80. 

to  be  fractured  a  short  distance  below  the  short  process,  pre- 
senting the  appearance  shown  in  the  engraving.  The  broken 
ends  of  the  bone  were  completely  and  transversely  displaced. 

When  Dr.  Weir  caused  the  patient  to  perform  the  Valsal- 
vian  experiment,  the  fragments  came  into  apposition,  and  the 
line  of  the  bone  became  regular  ;  but  the  posterior  portion  of 
the  membrana  tympani  projected  unduly  forward  from  want 
of  support.  In  a  few  moments  the  displacement  recurred,  with 
corresponding  sinking  of  the  posterior  of  the  drum  membrane. 
Dr.  Weir's  colleagues — Drs.  Hackley  and  Simrock — thought  that 
a  faint  whitish  line,  posterior  to  the  malleus,  might  be  a  cicatrix 
from  a  laceration  of  the  drum-head.  The  patient  did  not  return 
to  the  infirmary. 


1  Transactions  American  Otological  Society,  1870. 


CHAPTER  XI. 

ACUTE  CATAKKHAL  INFLAMMATION  OF  THE  MIDDLE  EAR 

Nomenclature.  — Statistics.  — Symptoms. — Treatment.  —  Leeches. — Paracentesis .  — Sub- 
acute  Catarrh. — Hemorrhagic  Inflammation  of  the  Middle  Ear. — Aural  Hemor- 
rhage in  Bright's  Disease. — Vascular  Tumors  of  the  Drum-head. 

THE  practitioner  or  student,  who  is  entering  upon  the  study  of 
aural  disease,  will  find,  I  think,  some  advantage  in  beginning 
with  an  outline  map  of  the  territory  which  he  is  about  to  tra- 
verse. For  this  reason,  at  this  point  as  at  the  beginning  of  the 
discussion  of  diseases  of  the  external  ear,  a  list  or  classification 
of  the  diseases  of  the  middle  ear  is  given  : 

I.  Acute  catarrhal  inflammation. 
II.  Sub-acute  catarrhal  inflammation. 

III.  Hemorrhagic  inflammation. 

IV.  Acute  and  sub -acute  suppurative  inflammation. 
V.  Acute  serous  inflammation. 

VI.  Chronic  non-suppurative  inflammation. 
VII.  Chronic    suppurative    inflammation,   with   its  conse- 
quences. 
VIII.  Neuralgia  of  the  middle  ear. 

If  we  were  to  form  our  estimate  of  the  frequency  of  acute 
catarrhal  or  suppurative  inflammation  of  the  middle  ear,  simply 
from  the  number  of  cases  that  are  found  in  the  statistical  tables 
of  writers  on  these  diseases,  we  should  come  to  an  erroneous 
conclusion  as  to  the  number  of  persons  who  suffer,  at  one  time 
or  another,  from  them.  Acute  catarrh  of  the  middle  ear,  is 
actually  a  very  common  disease  in  our  northern  climates.  It  is 
rather  difficult  to  find  a  grown  person  who  has  not,  at  one  time 
or  another,  suffered  from  "  earache."  Earache  is  the  popular 
name  for  acute  catarrh  of  the  middle  ear.  My  own  statistics 
show  that  of  4800  cases  of  aural  disease,  seen  in  my  private 
practice,  174  were  cases  of  acute  catarrh  of  the  middle  ear,  137 
of  acute  suppurative,  and  3  of  acute  hemorrhagic  inflammation 
of  the  same  part. 


STATISTICS   OF   ACUTE  DISEASE   OP   MIDDLE   EAE. 


279 


Biirkner's  tables/  in  a  total  of  43,730,  only  exhibit  a  total  of 
6180  acute  affections  of  the  middle  ear.  This  table  includes 
acute  myringitis  and  acute  inflammation  of  the  Eustachian  tube 
— diseases  that  are  properly  included  among  those  of  the  middle 
ear. 

The  following  table,  also  illustrates  the  comparative  infre- 
quency  with  which  acute  affections  of  the  middle  ear,  are  seen 
in  hospitals.  It  will  be  found,  however,  that  the  proportion  of 
acute  aural  diseases  increases,  year  by  year,  when  special  hos- 
pitals are  provided. 

The  advance  of  otology  has  been  greatly  hindered  by  the 
notion  quite  prevalent  in  the  profession,  as  well  as  among  the 
laity,  that  while  a  nurse  or  mother  is  quite  competent  to  treat 
an  acute  aural  disease,  a  physician,  and  perhaps  a  specialist,  is 
needed  when  it  becomes  chronic. 


Table  showing  the  Proportion  of  Acute  Cases  of  Disease  of  the  Middle  Ear  to  the 
Whole  Number  of  Aural  Cases.9 


Hospital. 

Year  or  period. 

Whole 
number. 

Acute  in- 
flammation 
of  middle 
ear. 

Manhattan  (New  York)  Eye  and  Ear  Hospital  .  . 
New  York  Eye  and  Ear  Infirmary   

20  years 
1889 

20,103 
3,738 

3,049 
469 

New  York  Ophthalmic  and  Aural  Institute  
Brooklyn  Eye  and  Ear  Hospital  

1889 
21  years 

983 
23,729 

142 
3,203 

Massachusetts  Eye  and  Ear  Infirmary  

1889 

3,952 

362 

Salem  Hospital  

15  years 

1,276 

306 

St.  Michael's  Hospital  (Newark,  N.  J.)  

1888 

615 

183 

Newark  Eye  and  Ear  Infirmary  

1889 

1,296 

81 

Illinois  Eye  and  Ear  Infirmary  

1885-1886 

1,971 

124 

Buffalo  Eye  and  Ear  Infirmary  

1889 

171 

28 

57,834 

7,947 

It  will  be  seen  from  the  above  table,  that  acute  affections  of 
the  middle  ear  were  about  one-seventh  of  the  whole  number. 
This  corresponds  pretty  accurately  with  Biirkners  statistics. 

That  this  disproportion  does  not  arise  from  an  actual  rarity 
of  the  affection,  I  think  a  little  thought  will  show.  These  pain- 
ful diseases  very  often  never  reach  a  practitioner,  and  are  treated 
at  home,  a  fact  which  accounts  for  their  relative  infrequency  in 
statistical  tables. 


1  Archiv  fur  Ohrenheilkunde,  Bd.  XX.,  1883. 

2  Sub-acute  cases  are  not  included  in  this  table. 


280  ACUTE  CATARRH  OF  MIDDLE  EAR. 

Every  general  practitioner  will  at  once  recall  the  fact,  that 
it  is  often  incidentally  mentioned,  when  perhaps  he  is  visiting  a 
family  suffering  from  other  diseases,  that  one  of  the  children  has 
had  a  severe  earache  all  night,  and  that  there  has  been  great 
difficulty  in  quieting  the  fearful  pain.  Very  often,  indeed,  the 
fact  will  be  added,  that  the  pain  is  not  yet  subdued,  and  that 
the  family  have  quite  exhausted  the  means  at  their  disposal  for 
relieving  it ;  and  yet,  taught  by  tradition  and  experience,  they 
do  not  expect  anything  from  the  physician,  whose  aid  becomes 
so  efficacious  for  the  pain  of  colic  or  of  peritonitis.  It  is  to  be 
feared  that  many  physicians  stand  helplessly  by,  and  allow  an 
acute  catarrh  of  the  middle  ear  to  run  on  to  suppuration  of  the 
drum-head,  or,  worse  still,  to  periostitis  of  the  mastoid  or  to 
meningitis,  without  an  attempt  at  interference. 

A  little  later,  in  the  discussion  of  this  affection,  we  shall  dis- 
cover, I  think,  that  the  means  at  our  disposal  for  its  relief  are 
ample,  and  that  they  have  what  may  almost  be  termed  a  bril- 
liant effect,  when  properly  used  ;  but  I  wish  in  the  outset  to  im- 
press the  fact  upon  the  minds  of  my  readers  that  the  commonly 
neglected  earache  of  the  household  is  identical  with  the  disease 
known  as  acute  catarrhal  inflammation  of  the  middle  ear.  It 
will  then  be  evident  that  we  are  dealing  with  an  extremely 
practical  subject,  and  one  in  which  every  family  practitioner  is, 
or  should  be,  very  much  interested. 

The  symptoms  of  this  affection  are  so  characteristic  that  in 
the  adult  they  point  unmistakably  in  the  most  cases  to  its  seat. 
I  say  in  the  adult,  for  in  young  children  who  have  not  yet  learned 
to  speak,  the  diagnosis  sometimes  becomes  very  difficult,  and  it 
is  not  always  possible. 

Symptoms.  — The  symptoms  of  acute  catarrh  may  be  enumer- 
ated in  the  following  order  : 

Subjective. 

1.  Pain,  referred  to  the  depth  of  the  ear,  or  of  a  neuralgic 
character,  and  passing  from  the  throat  to  the  ear. 

2.  A  sense  of  fulness  in  the  same  part. 

3.  Noises  in  the  ear. 

4.  An  unnatural,  hollow  sound  of  one's  own  voice. 

Objective. 

1.  Vascular  injection. 

2.  Bulging  outward  of  the  membrana  tympani. 

3.  Impairment  of  hearing. 

4.  Catarrh  of  the  pharynx  and  Eustachian  tubes. 

5.  Fever. 


ACUTE  CATAEBH  OF  MIDDLE  EAE.  281 

The  pain  is  very  often  the  first  symptom  that  is  observed. 
Children  old  enough  to  speak  awake  from  sleep  crying,  "My 
ear,  my  ear."  Adults  find  themselves  without  warning  attacked 
by  a  pain  which  causes  the  most  intense  agony — a  pain  which 
forces  the  strongest  men  to  shriek  and  tremble,  while  children 
affected  with  such  a  disease  soon  cause  the  attendants  to  believe 
that  the  brain  must  be  the  seat  of  trouble.  Sometimes,  however, 
patients  with  good  habits  of  observation  notice  that  the  pharynx 
feels  thickened  and  full,  and  that  the  throat  is  sore,  a  short 
time  before  the  pain  in  the  ear. begins.  I  am  inclined  to  believe 
that  most  patients  are  aware  of  what,  for  the  want  of  a  better 
name,  may  be  termed  a  thickness  of  hearing,  a  fulness  in  the 
ears,  before  the  attack  of  pain  occurs.  This  pain  is  described  by 
some  patients  as  beginning  in  the  throat  and  crawling  along  the 
Eustachian  tube.  It  is  a  disease,  however,  which  may  be  said 
to  be  sudden  in  its  origin,  and  one  which  jumps  at  a  bound  to  its 
height.  It  will  pass  over  the  acme,  in  most  cases,  unless  at  once 
arrested,  into  acute  suppuration  of  the  middle  ear ;  a  disease 
which,  strangely  enough,  some  practitioners  seem  to  invite, 
judging  from  the  expression  once  at  least  commonly  heard, 
'"'  It  is  a  gathering  of  the  ear,  from  which  we  shall  get  no  relief 
until  suppuration  is  established."  I  intend  to  combat  this  idea 
in  the  discussion  of  the  treatment.  It  is  certainly  an  erroneous 
and  mischievous  view  of  a  serious  disease. 

The  sensations  of  fulness,  the  noises  in  the  ear  in  acute 
inflammation,  are  very  distressing.  The  latter  symptom,  the 
technical  tinnitus  aurium,  usually  lessens  and  changes  its  char- 
acter with  a  cessation  of  the  pain.  It  changes  from  a  puffing 
sound,  like  the  puff  of  a  miniature  steam-engine,  to  a  ringing  or 
buzzing  sensation.  The  feeling  of  fulness  usually  lasts  for  some 
days  after  the  pain  has  passed  away. 

As  I  have  said,  the  diagnosis  of  this  disease  is  often  difficult 
in  young  children,  because  they  are  unable  to  locate  the  seat  of 
the  pain  in  words.  If,  however,  we  watch  a  child  carefully  who 
is  suffering  from  pain  in  the  ear,  we  can  usually  narrow  it  down 
to  the  region  of  the  head.  Then  by  means  of  pressure  upon  the 
tragus,  observing  if  the  child  winces  at  this,  we  can  generally 
form  a  conclusion  as  to  the  origin  of  the  pain.  The  disease  with 
which  infantile  catarrh  of  the  middle  ear  is  apt  to  be  confounded 
is  an  affection  of  the  membranes  of  the  brain.  When  we  re- 
member the  anatomy  of  the  ear,  especially  that  of  the  tympanic 
cavity,  we  can  readily  appreciate  the  fact  that  an  acute  inflam- 
mation of  the  middle  ear,  may  easily  cause  hypersemia  of  the 
membranes  of  the  brain  through  the  roof  of  the  tympanic  cav- 
ity, or  of  the  labyrinth,  through  the  fenestrse  of  the  thin  wall 


282  SYMPTOMS   OF   ACUTE   CATARRH. 

separating  the  tympanum  from  the  cochlea  and  semicircular 
canals.  When  we  also  consider,  as  shown  by  Politzer,  that  the 
vascular  communication  is  direct,  through  vessels  situated  in 
this  partition,  we  are  not  surprised  that  a  congestion  or  inflam- 
mation of  the  middle  ear,  especially  in  infants  and  young  chil- 
dren, may  cause  very  serious  head  symptoms.  Besides  this,  the 
physiological  process  of  teething,  is  often  credited  with  a  great 
deal  of  pain,  which  more  properly  belongs  to  the  ear.  With  a 
certain  class  of  what  may  be  called  easy-going  practitioners,  the 
diagnosis  of  difficult  dentition,  is  often  sufficient  to  cover  a  mul- 
titude of  painful  symptoms.  Accordingly,  gums  are  needlessly 
lanced,  and  dangerous  delays  are  allowed,  until  a  discharge  of 
pus  through  the  drum-head,  makes  the  diagnosis  for  the  little 
sufferer. 

Pouring  warm  water  into  the  auditory  canal  will  usually 
temporarily  relieve  an  infantile  earache  ;  and  in  this  procedure 
we  have  a  means  of  diagnosis  which  is  always  at  hand.  I  have 
seen  children  who  were  crying  with  pain  from  inflammation  of 
the  middle  ear,  go  to  sleep  in  a  few  moments  after  warm  water 
has  been  poured  into  the  canal.  Sometimes,  however,  this  pro- 
cedure will  fail  to  give  relief,  and  we  must  depend  for  a  diag- 
nosis upon  the  objective  symptoms,  found  in  the  color  of  the 
membrana  tympani,  of  which  I  shall  soon  speak. 

Adults  sometimes  mistake  the  pain  from  inflammation  of  the 
lining  membrane  of  the  middle  ear,  for  what  is  termed  neuralgia. 
I  have  seen  cases  where  an  anti-neuralgic  treatment  by  means 
of  quinine  and  opium,  had  been  tried  in  vain  for  a  disease  which 
was  really  an  inflammation  of  the  mucous  membrane ;  but  adults 
usually  locate  the  seat  of  trouble  with  exactness  and  accuracy. 
The  pain  is  indeed  neuralgic,  and  a  moment's  consideration  of 
the  rich  supply  of  nerves  to  the  cavity  of  the  tympanum,  will 
give  the  reason  for  the  fact  that  the  pain  follows  the  course  of 
the  fifth  nerve. 

This  mistake  in  diagnosis  is  very  similar  to  the  one  made 
when  acute  glaucoma  is  thought  to  be  neuralgia.  Neuralgia  of 
the  tympanic  cavity  is  a  very  rare  affection.  When  it  does 
occur,  the  absence  of  the  symptoms  of  inflammation  will  indicate 
the  true  diagnosis. 

The  objective  symptoms  are  chiefly  to-  be  sought  in  the  mem- 
brana tympani.  There  is  sometimes  a  pinkish  hue  to  the  whole 
membrane,  again  the  vascular  injection  is  around  the  periphery 
of  the  drum-head,  and  along  the  handle  of  the  malleus,  while 
the  other  parts  of  the  membrane  remain  of  their  normal  color. 
An  acute  inflammation  occurring  in  a  drum  membrane  rigid, 
thickened,  and  opaque  from  former  inflammation,  is  more  apt 


SYMPTOMS  OF  ACUTE  CATARRH.  28)3 

to  show  localized  redness  than  the  diffuse  pinkish  tint,  that  is 
seen  when  inflammation  occurs  in  a  membrane  that  has  been 
previously  healthy. 

At  other  times  the  redness  is  so  intense  as  almost  to  prevent 
any  recognition  of  the  drum-head,  except  as  an  evenly  red  sur- 
face in  which  no  vessels  can  be  traced. 

I  think  there  is  always  some  increased  vascularity  of  this 
membrane,  in  every  case  of  acute  inflammation  of  the  lining  of 
the  tube  and  the  cavity  of  the  tympanum,  so  that  we  may  find 
in  this  symptom  the  deciding  point  in  doubtful  cases,  even  in 
an  infant.  The  membrane  has,  however,  at  times  the  appear- 
ance of  glass  that  has  been  breathed  upon,  without  any  evident 
increase  in  vascularity,  even  where  there  is  acute  inflammation 
going  on  in  the  middle  ear. 

The  impairment  of  hearing  is  not  always  marked  in  the  stage 
of  pain.  The  hearing  power  may  even  be  augmented  and  be 
painfully  acute  during  the  first  stage  of  the  disease.  In  cases 
of  chronic  aural  catarrh,  in  which  an  acute  inflammation  had 
supervened,  I  have  known  many  instances  where  the  acuteness 
of  hearing  was  found  on  accurate  examination  to  be  markedly 
increased.  It  may  be  increased  also  in  acute  cases  occurring  in 
persons  whose  ears  had  been  previously  healthy  ;  that  is  to  say, 
sounds  may  seem  very  loud  to  them.  In  such  a  case  there  is 
probably  hypersemia  of  the  vestibule  or  cochlea,  besides  that  of 
the  tympanum. 

Bulging  outward  of  the  membrana  tympani  is  a  symptom 
that  may  often  be  observed  after  the  first  forty-eight  hours  of 
an  attack  of  acute  catarrh.  If  the  disease  continue  longer  in 
an  acute .  form,  spontaneous  perforation  is  apt  to,  but  does  not 
always  occur.  This  bulging  outward  I  have  most  frequently 
observed  in  the  posterior  and  inferior  quadrant,  but  also  in 
ShrapnelPs  membrane,  and  usually  in  the  posterior  portion  of 
this  membrane.  It  is  sufficiently  marked  to  be  detected  by 
any  one  who  is  at  all  familiar  with  the  examination  of  the 
normal  membrane.  In  rare  cases — I  believe  I  have  seen  but 
two  in  my  experience — the  imperforate  membrana  tympani 
will  be  found  to  pulsate  synchronously  with  the  pulsations  of 
the  heart.  As  is  well  known,  it  is  quite  common  to  observe  a 
pulsation  of  the  vessels  of  the  cavity  of  the  tympanum  in  cases 
of  acute  and  chronic  suppuration  of  this  part  ;  but  pulsation 
of  the  imperforate  membrana  tympani  is  a  rare  symptom. 
There  must  be  great  increase  of  the  tension  of  the  membrane 
from  the  pressure  of  the  blood  column  or  of  mucus  behind  it 
when  this  occurs.  Increased  secretion  from  the  pharynx  and 
region  of  the  posterior  nares  is  almost  always  observed  in 


284  CAUSES   OF   ACUTE  CATARRH. 

cases  of  acute  catarrh ;  but  it  requires  but  a  mere  mention  at 
this  point. 

Febrile  symptoms  are  almost  always  present  in  cases  of  the 
disease  under  discussion.  The  temperature  is  usually  consider- 
ably increased  in  a  severe  case,  so  that  the  general  aspect  of  the 
patient,  suffering  from  great  local  pain,  impairment  of  hearing, 
and  a  dry,  heated  skin,  is  one  of  intense  suffering.  Yet  this  is 
the  disease  which  many  physicians  allow  to  run  its  course, 
without  any  of  the  antiphlogistic  treatment  that  they  would  at 
once  resort  to,  were  any  other  organ  of  the  body  similarly  at- 
tacked. 

In  completing  this  description,  it  should  also  be  said,  that 
there  are  cases  of  acute  catarrh  of  the  middle  ear  in  adults  as 
well  as  in  children,  where  while  the  symptoms  of  impairment  of 
hearing,  a  sense  of  stuffiness  in  the  head,  redness  and  bulging 
of  the  drum-head,  a  peculiar  hollow  sound  of  one's  own  voice,  are 
marked,  there  is  no  considerable  pain,  or  if  there  has  been,  it 
has  passed  away  before  the  physician  has  reached  the  patient. 
These,  however,  are  exceptional  cases. 

Causes. — The  causes  of  this  disease  are  manifold.  Any  un- 
due exposure  to  the  influence  of  cold  may  produce  acute  catarrh 
of  the  middle  ear.  Getting  the  feet  wet,  the  surface  of  the  body 
chilled  by  standing  or  walking  in  the  cold,  are  frequent  causes 
of  earache.  A  draught  of  air  blowing,  for  instance,  through  the 
window  of  a  railway  carriage  in  rapid  motion,  is  sometimes  a 
cause  of  acute  catarrh. 

Ducking  the  head  under  water,  and  allowing  the  water  that 
enters  the  auditory  canal  to  remain  there,  is  another  cause. 

Surf -bathing,  especially  in  those  people  who  habitually  suffer 
from  catarrh  of  the  nares  and  pharynx,  thus  may  become  a 
cause  of  acute  inflammation  of  the  middle  ear,  as  well  as  of  the 
auditory  canal.  The  salt-water  may  enter  the  nostrils  and  Eus- 
tachian  tube  and  cause  the  disease,  or  a  wave  may  deluge  the 
auditory  canal  and  injure  the  drum-head,  and  thus  affect  the 
middle  ear.  Yet,  considering  the  great  extent  to  which  surf-, 
bathing  is  practised  in  the  United  States,  the  number  of  cases 
of  inflammation  of  the  ear  caused  by  it  is  very  small.  I  have 
spent  several  summers  where  surf-bathing  is  extensively  en- 
joyed, and  I  have  heard  very  little  of  its  evil  effects.  I  believe 
the  cases  of  disease  of  the  ear  caused  by  it,  occur  chiefly  among 
careless  and  ignorant  bathers,  or  in  those  who  already  suffer 
from  chronic  aural  or  naso-pharyngeal  disease.  Prolonged 
bathing  and  diving  in  still  water,  are  much  more  apt  to  cause 
congestion  of  the  middle  ear  than  surf -bathing. 


CAUSES   OF   ACUTE   CATARRH.  285 

Many  cases  of  aural  disease  are  said  by  those  who  suffer 
from  them  to  have  originated  in  the  following  way.  "  I  got  my 
ears  full  of  water  and  never  could  get  it  out,"  is  the  fanciful 
statement  of  many  patients  who  mistake  the  feeling  of  fulness 
in  an  inflamed  middle  ear,  for  that  from  water  remaining  in  it. 
Surf -bathing  is  of  such  value  as  a  tonic  to  many  debilitated  sys- 
tems that  I  do  not  hesitate  to  advise  it,  even  to  patients  with 
aural  disease,  under  proper  precautions,  such  as  : 

1.  Take  a  bath  of  not  more  than  five  or  ten  minutes  in  duration. 

2.  If  the  ears  are  affected  by  chronic  suppuration,  close  the 
meatus  with  cotton. 

3.  Never  allow  a  wave  to  strike  the  side  of  the  head. 

4.  Indulge  very  sparingly,  if  at  all,  in  swimming  or  diving 
through  the  breakers. 

Constitutional  diseases,  such  as  small-pox,  scarlet  fever,  and 
measles,  in  which  the  pharynx  is  affected,  are  very  common 
sources  of  acute  aural  catarrh.  Pneumonia  and  bronchitis  very 
often  have  this  affection  as  a  consequence.  Coryza  or  cold  in 
the  head,  however  caused,  very  often  gives  rise  to  acute  inflam- 
mation of  the  ear. 

It  arises  in  the  course  of  syphilitic  affections  of  the  pharynx 
and  posterior  nares ;  but,  contrary  to  what  has  been  said  by 
some  authors,  I  have  found  no  pathognomonic  evidences  of  syph- 
ilis in  the  character  of  the  pain  or  the  appearance  of  the,  mem- 
brana  tympani  in  such  cases. 

Cerebro-spinal  meningitis,  is  also  a  prolific  source  of  acute 
inflammation  of  the  middle  ear. 

The  origin  of  acute  catarrh,  is  chiefly  to  be  sought  for  in  the 
faucial  extremity  of  the  Eustachian  tube,  and  not  in  the  audi- 
tory canal.  This  explains  the  fact,  that  it  is  much  more  impor- 
tant for  patients  liable  to  aural  disease,  to  protect  the  external 
surface  of  the  body  and  the  extremities  from  the  cold,  than  the 
meatus  and  auricle. 

Yet  it  is  not  to  be  denied,  that  inflammation  of  the  middle 
ear  does  occasionally  extend  from  the  canal,  through  the  mem- 
brana  tympani,  and  not  through  the  Eustachian  tube,  for  a 
draught  of  air  upon  the  side  of  the  head  will  produce  acute  aural 
catarrh,  and  if  cold  water  enter  the  ear  through  the  meatus  ex- 
ternus,  and  remain  for  a  considerable  time,  it  may  also  produce 
acute  catarrh  of  the  middle  ear. 

The  use  of  the  nasal  douche  for  the  treatment  of  naso-pha- 
ryngeal  catarrh,  may  also  produce  acute  inflammation  of  the 
ear,  as  I  first  showed.1  My  experience  has  since  been  confirmed 
by  many  other  observers. 

1  Archives  of  Ophthalmology  and  Otology,  vol.  i.,  No.  1. 


286  ACUTE  CATARRH — TREATMENT. 

In  the  description  of  the  treatment  of  the  pharj^nx  and  nares 
in  the  course  of  chronic  aural  inflammation,  the  subject  of  the 
use  of  the  nasal  douche  will  be  more  fully  discussed. 

The  occurrence  of  acute  catarrh  of  the  ear,  in  scarlatina, 
measles,  naso-pharyngeal  catarrh,  and  pneumonia,  is,  I  think, 
favored,  by  the  common  practice  of  giving  large,  or  compara- 
tively large,  doses  of  sulphate  of  quinine  in  these  cases.  This 
invaluable  remedy  should,  in  my  opinion,  be  given  with  great 
caution  in  these  diseases,  since  the  disposition  to  extension  of 
the  inflammation  to  the  middle  ear,  exists  strongly  in  all  these 
constitutional  affections.  Quinine  is  quite  sure  to  aggravate 
aural  symptoms,  if  they  already  exist,  and  in  young  children  it 
may  excite  them.  I  have  several  times  seen  children  suffering 
from  acute  aural  catarrh,  in  whose  ears  the  administration  of 
quinine  had,  from  the  very  first  dose,  steadily  aggravated  the 
pain,  until  the  discharge  of  pus  from  the  tympanic  cavity  ex- 
plained the  high  temperature,  which  should  have  been  combated 
by  local  antiphlogistic  remedies,  instead  of  by  an  antipyretic.1 

What  has  been  said  of  quinine  refers  also  with  equal  force  to 
the  various  newly  found  drugs  for  reducing  temperature — anti- 
pyrine,  phenacetin,  and  so  forth.  Winter-green  and  salicyne 
should  be  used  with  caution  in  cases  with  sensitive  ears. 

Treatment. — The  proper  treatment  of  acute  aural  catarrh  is 
predominantly  an  antiphlogistic  one.  The  disease  is  an  inflam- 
mation of  the  severest  form,  and  can  only  be  successfully  com- 
bated by  such  means  as  local  blood-letting,  quiet,  warmth,  and 
opium.  As  has  been  said,  a  neuralgia  of  the  middle  .ear,  that  is 
to  say,  pain  without  other  symptoms  of  inflammation,  is  ex- 
tremely rare,  yet  an  inflammation  of  the  middle  ear  is  very  often 
treated  as  would  be  a  case  of  facial  neuralgia  ;  or  we  might  even 
say,  that  the  ordinary  treatment  for  acute  aural  inflammation  is 
pre-eminently  empirical  and  without  reason.  From  the  time  of 
the  ancients  down  to  our  own  day,  all  kinds  of  decoctions  and 
mixtures  have  been  poured  into  the  ears  to  relieve  earache. 
Some,  of  these  agents  are  of  a  negative  or  slight  value  ;  many  of 
them  are  of  a  positively  harmful  nature.  To  the  former  class 
belong  such  applications  as  sweet-oil  and  laudanum,  glycerine, 
molasses,  and  so  on.  To  the  latter  class  belong  Haarlem  oil, 
Cologne  water,  ether,  and  all  stimulating  applications.  Poul- 
tices are  remedies  often  used  ;  but  while  they  generally  quiet 
pain,  their  application  is  so  dangerous  to  the  integrity  of  the 
drum  membrane,  especially  if  they  be  used  for  many  hours  in 

1  See  Medical  Record,  February  8,  1883,  and  Transactions  of  the  Medical  Society  of 
the  State  of  New  York,  1883,  as  well  as  an  article  on  "Colds  in  the  Head,"  in  the 
Transactions  of  the  same  Society  of  1880,  p.  342. 


ACUTE  CATARRH — TREATMENT.  287 

succession,  that  the  practitioner  will  do  well  to  avoid  them,  un- 
less other  means  cannot  be  employed,  or  when  the  latter  prove 
ineffectual.  In  some  cases,  however,  the  urgency  of  the  pain 
will  demand  that  poultices  be  employed.  The  chief  thing  to  be 
done  in  this  disease  is  to  decrease  the  heat,  swelling,  and  vascu- 
larity  of  the  parts.  Applications  of  a  stimulating  nature,  made 
to  the  membrana  tympani,  certainly  cannot  do  this  ;  and  mere 
emollients,  such  as  sweet-oil,  have  a  very  transitory  effect. 

I  would  place  local  blood-letting  as  the  chief  and  first  remedy 
in  acute  aural  catarrh.  This  blood-letting  should  be  performed  by 
means  of  leeches  applied  to  the  tragus,  and  not  to  the  mastoid  pro- 
cess. Wilde  and  Troltsch  have  taught  the  profession  that  this 
is  the  best  point  for  the  application  of  leeches  in  inflammation  of 
the  ears,  and  the  reasons  therefor.  At  this  point,  the  blood  is  most 
easily  drawn  from  the  cavity  of  the  tympanum — the  vessels  sup- 
plying it,  and  the  drum  membrane,  inosculating  here.  The  ap- 
plication of  from  one  to  six  leeches,  according  to  the  severity  of 
the  disease  and  the  age  of  the  patient,  will  usually  be  sufficient 
to  quiet  the  most  severe  pain  in  the,  ear,  and  to  check  the  intens- 
est  form  of  catarrhal  inflammation.  I  have  seen  almost  magical 
effects  from  their  use.  One  of  the  most  striking  of  the  cases  in 
my  note-book  is  the  following :  I  was  called  on  a  very  severe 
winter's  day  to  see  a  young  gentleman  in  a  neighboring  city,  who 
had  been  suffering  for  two  days  from  acute  pain  referred  to 
the  ear.  I  found  the  symptoms  of  acute  aural  catarrh,  in  a  red- 
dened but  intact  drum  membrane,  congested  pharynx,  and  so 
forth.  When  I  entered  the  room  he  seemed  to  be  in  mortal  agony. 
He  said  that  he  had  not  slept  for  forty-eight  hours,  and  his  anx- 
ious countenance  verified  his  assertion.  I  at  once  sent  out  for 
some  leeches,  and  caused  one  to  be  applied  to  each  ear,  and  before 
they  had  dropped  from  the  tragus  he  was  asleep,  and  went  rap- 
idly on  to  perfect  recovery.  Such  cases  might  be  multiplied,  for 
they  are  of  frequent  occurrence  in  hospital  and  private  practice. 

Leeches  are,  however,  a  troublesome  remedy,  and  in  country 
districts  they  are  not  always  to  be  had.  In  their  absence  I  place 
the  use  of  warm  water  as  next  in  efficiency.  This  should  be 
poured  continuously  into  the  ear,  and  not  used  by  means  of  a 
syringe,  as  I  have  known  patients  to  employ  the  water  when 
told  to  pour  warm  water  into  the  ear.  The  fountain  syringe  or 
the  Fayette  douche  (see  illustration  on  page  120)  is  the  best 
means  of  which  I  know  for  applying  warm  water  to  the  ear. 
Sometimes  the  warm  water  is  unpleasant,  instead  of  grateful, 
to  the  patient,  and  then  the  vapor  of  water  or  the  smoke  from  a 
cigar  or  pipe  may  be  conducted  into  the  ear.  Children  may  some- 
times be  relieved  in  the  beginning  of  an  attack  of  acute  aural 


288  ACUTE  CATARRH — TREATMENT. 

catarrh,  by  breathing  into  the  affected  ear  for  a  very  few  min- 
utes. If  leeches  cannot  be  had,  and  the  use  of  warm  water  or 
of  steam  does  not  subdue  the  pain,  cups — wet  or  dry — applied 
around  the  auricle,  are  sometimes  of  use,  as  well  as  blisters. 

Poultices,  as  I  have  said,  are  only  to  be  used  as  a  last  resort. 
Then  they  should  be  made  small  enough  to  be  put  in  the  canal, 
and  one  may  also  be  placed  around  the  ear,  leaving  the  auricle 
free  ;  and  their  use  should  be  given  up  as  soon  as  the  inflamma- 
tion has  abated. 

If  the  patient  or  his  friends  are  told  to  apply  the  leeches,  the 
exact  spot  upon  which  they  are  to  be  placed  should  be  marked 
with  ink,  or  they  will  be  put  on  the  lobe,  or  on  the  neck,  or  in 
some  other  position  where  their  use  will  do  no  good.  I  have 
quite  often  found,  that  a  neglect  to  state  just  where  the  leeches 
should  be  applied,  has  caused  all  the  efforts  to  relieve  pain  to  be 
of  no  value.  Rohland's  styptic  cotton — a  preparation  of  cotton 
in  a  solution  of  alum — prepared  by  Dr.  Rohland,  of  this  city,  will 
be  found  a  very  efficient  means  of  arresting  the  hemorrhage  from 
a  leech-bite.  The  bleeding  should,  however,  usually  be  encour- 
aged, by  the  use  of  warm  compresses,  for  an  hour  after  the 
leech  has  dropped  from  the  ear. 

Scarification  of  the  drum-head,  as  recommended  by  Blake,  is 
also  of  service  in  mild  cases.  It  requires  a  much  more  practised 
hand  for  its  performance,  however,  than  a  paracentesis. 

Paracentesis  of  the  drum  membrane  is  a  very  efficient  remedy 
at  times,  when  there  is  bulging  of  the  drum-head,  and  we  see 
that  perforation  is  imminent ;  or  even  in  cases  of  prolonged  pain 
without  bulging  of  the  membrane,  when  the  leeches  have  been 
used  at  too  late  a  period,  or  have  proved  ineffectual. 

Schwartze,  of  Halle,  taught  us  the  value  of  this  means  of 
treatment  in  acute  cases,  a»d  I  have  found  it  of  great  value.  I 
would  even  pass  a  cataract  needle  through  the  posterior  portion 
of  the  membrana  tympani,  in  any  case,  whether  bulging  was 
seen  or  not,  when  the  use  of  leeches  did  not  markedly  diminish 
the  severe  pain  within  a  few  hours.  I  have  done  so  with  strik- 
ing effect  in  some  cases.  Yet  leeches  and  warm  water,  if 
promptly  used,  will  usually  check  the  progress  of  even  the  se- 
verest case.  Very  often,  however,  we  are  not  called  until  the 
disease  has  advanced  so  far  as  to  involve  every  part  of  the 
middle  ear,  when  periostitis  of  the  mastoid  has  occurred,  and  sup- 
puration seems  to  be  inevitable. 

Paracentesis  of  the  membrana  tympani  should  be  performed 
while  the  head  of  the  patient  is  well  supported,  and  a  good  light 
is  thrown  upon  the  membrane  by  means  of  the  otoscope  attached 
to  a  forehead  band.  A  needle,  such  as  shown  on  the  next  page, 


ACUTE  CATARRH — PARACENTESIS.  289 

is  the  one  I  employ.  The  point  of  opening  should  be  determined 
by  the  seat  of  the  greatest  amount  of  bulging,  which  I  have 
found  generally  to  be  in  Shrapnell's  membrane,  and  in  the  pos- 
terior and  inferior  quadrant  of  the  membrane. 

I  have  tried  the  instruments  with  an  angular  handle,  but  I 
have,  after  much  experience,  concluded  that  a  straight  instru- 
ment is  so  much  more  easily  managed,  that  this  facility  in  use 
much  more  than  completely  balances  any  value  from  not  shut- 
ting off  the  light  from  the  canal,  said  to  belong  to  the  other  in- 
struments. A  needle,  such  as  is  used  in  the  operation  of  di- 
scission  of  a  soft  cataract,  is  a  very  good  instrument  for  making 
an  opening  into  the  membrana  tympani. 

The  operation  causes  so  little  pain  and  it  is  so  brief,  that  this 
element  does  not  enter  into  the  consideration  of  the  surgeon.  I 
have  found  the  light  of  a  candle  about,  the  best  and  most  con- 
venient source  of  illumination,  when  the  operation  is  to  be  done 
in  a  sick-room,  and  the  patient  is  in  bed.  For  acute  cases  a 
thorough  puncture,  through  which  the  blood,  mucus,  or  pus  can 
be  drawn,  is  usually  an  opening  large  enough  to  relieve  pain. 
I  have  more  frequently  performed  the  operation  in  cases  where 


FIG.  81. — Paracentesis  Needle. 

the  severity  of  the  pain  has  passed,  and  yet  I  have  also  per- 
formed it  with  the  happiest  of  immediate  results  when  the  pa- 
tient was  at  the  height  of  distress. 

If  we  find  on  examination  that  the  mastoid  region  is  red,  hot, 
tender,  and  swelled,  it  will  be  often  necessary  to  make  an  inci- 
sion through  its  tissues  down  to  the  periosteum  ;  but  it  is  only 
very  rarely  that  this  is  the  case  in  acute  aural  catarrh.  Such  a 
state  of  things  is  more  apt  to  be  found  in  acute  or  sub-acute  sup- 
puration, or  as  a  result  of  chronic  suppuration,  under  which 
heads  the  subject  will  be  fully  discussed. 

The  condition  of  the  pharyngeal  mucous  membrane  should 
at  the  same  time  be  attended  to,  by  means  of  gargles  and  ex- 
ternal applications.  A  saturated  solution  of  chlorate  of  potash 
forms  one  of  the  best  of  applications  to  the  pharynx,  while  the 
neck  may  be  enveloped  in  a  warm-water  poultice. 

The  Eustachian  catheter  and  Politzer's  method  of  inflating 
the  middle  ear  should  be  used  as  soon  as  the  acute  symptoms 
have  subsided,  say  in  forty-eight  hours.  If  employed  with  gen- 
tleness, there  need  be  no  fear  of  aggravating  the  subdued  in- 
flammation into  a  relapse.  Indeed,  inflation  often  relieves  pain 
by  emptying  and  ventilating  the  tympanum. 
19 


290  ACUTE  CATARRH — TREATMENT. 

The  hearing  should  be  accurately  tested  by  means  of  the 
watch  and  tuning-fork,  in  order  to  see,  after  the  pain  has  sub- 
sided, if  any  impairment  has  occurred.  If  only  one  ear  be 
uffected,  careless  patients  will  believe  that  the  hearing  is  per- 
fectly good,  after  the  pain  and  fulness  have  passed  away ;  but 
the  physician  should  be  sure  of  this  for  himself.  In  half-treated 
acute  catarrh,  are  laid  the  foundations  for  that  insidious  and 
obstinate  disease,  chronic  non-suppurative  inflammation  of  the 
middle  ear. 

While  this  energetic  local  treatment  is  carried  on,  the  atten- 
tion of  the  physician  should  be  turned  to  the  general  system. 
It  will  often  be  necessary  to  give  a  full  dose  of  opium  or  mor- 
phine at  bedtime.  It  is  somewhat  remarkable,  however,  that 
opium  has  very  little  effect,  when  used  without  local  depletion, 
to  quiet  the  pain  from  inflammation  of  the  middle  ear.  Very 
large  doses  will  be  taken  in  vain,  unless  the  local  means  that 
have  been  described  are  also  employetl. 

The  patient  should  be  kept  in  the  house,  and  in  a  well- 
warmed  room,  during  the  stage  of  pain  and  fever.  Pediluvia 
and  diaphoretics  are  hardly  necessary  in  case  the  pain  is  once 
subdued.  The  diet  should  be  nourishing.  The  patient  should 
be  enjoined  to  keep  his  skin  in  good  order  by  means  of  frequent 
bathing,  in  order  to  prevent  relapses.  The  improper  habits  of 
life,  or  the  exposures  to  cold,  that  have  induced  this  attack, 
should  be  carefully  sought  out,  in  order  that  future  ones  may 
be  avoided. 

A  daily  sponge-bath  in  a  warm  room,  using  cool  water  in 
summer  and  tepid  in  winter,  followed  by  vigorous  rubbing  with 
a  coarse  towel,  will  be  found  of  real  service  in  preventing  re- 
lapses of  aural  disease.  Not  every  patient,  however,  can  tolerate 
cold  water,  although  I  think  every  moderately  well  person  will 
be  the  better  for  a  daily  bath  of  the  whole  surface  of  the  body. 
A  little  discretion  must  therefore  be  allowed  the  individual  as 
to  the  temperature  of  the  water  used.  The  shower-bath  and  the 
plunge,  as  well  as  the  habit  of  pouring  water  into  the  ears, 
should  be  discouraged. 

The  practitioner  who,  while  treating  a  grave  constitutional 
disease,  finds  this  local  inflammation  breaking  out,  should  by 
no  means  allow  the  severity  or  danger  of  the  constitutional 
symptoms  to  prevent  him  from  the  proper  treatment  of  the 
acute  aural  catarrh.  The  local  and  constitutional  treatment 
can  well  go  on  together ;  while  the  neglect  of  the  ear  at  the 
proper  time  may  lead  to  irreparable  damage  not  only  to  the 
health  and  prosperity  of  the  patient,  but  it  may  destroy  his  life. 

We  cannot  be  too  much  impressed  with  the  fact  that  a  neg- 


ACUTE   CATARRH   IN  THE  EXANTHEMATA.  291 

lected  acute  aural  inflammation  may  lead,  through  suppuration 
of  the  middle  ear,  with  all  its  consequences  of  caries,  polypi, 
meningitis,  cerebral  abscess,  pyaemia,  to  the  most  deplorable 
results. 

Better  would  it  be  for  a  child  suffering  from  scarlet  fever  or 
measles  to  die  from  the  disease,  than  to  recover  from  the  con- 
stitutional affection  only  to  succumb,  with  great  misery,  to  the 
effects  of  the  neglected  inflammation  of  the  middle  ear.  It  is 
to  be  hoped  that  the  neglect  of  treatment  of  the  ear,  will  not  pre- 
vail in  the  next  generation  to  the  extent  that  it  does  in  ours* 

I  was  very  much  interested  in  a  complaint  made  by  a  dis- 
tinguished surgeon  of  New  York,  who,  in  a  discussion  upon  the 
effects  of  scarlet  fever  and  measles  upon  the  ear,  stated  that 
while  writers  on  aural  surgery  said  much  about  the  neglect  of 
diseases  of  the  ear,  occurring  during  the  course  of  the  exanthe- 
mata, he  had  found  no  means  of  doing  anything  to  prevent  the 
breaking  out  of  such  disease  while  the  measles  or  scarlet  fever 
were  going  on,  and  he  did  not  know,  after  all  the  warnings, 
that  there  was  anything  really  to  be  done.  Now,  in  answer 
to  this,  it  may  be  said  that  it  is  not  claimed  that  otitis  media 
may  be  always  averted  in  the  course  of  scarlatina  or  rubeola, 
but  sometimes,  if  the  physician  be  on  the  lookout  for  it,  it  may 
be  aborted,  so  to  speak.  If  a  child  begin  to  toss  its  head  about 
as  if  in  pain,  or  if  it  become  hard  of  hearing,  the  tragus  may 
be  at  once  examined  to  see  if  pressure  upon  it  cause  or  increase 
pain,  the  drum-head  may  be  looked  at  and  a  diagnosis  made. 
If  there  be  congestion  of  the  ear,  the  warm  douche  will  often 
relieve  it  at  once.  If  not,  we  have  blisters,  leeches,  and  para- 
centesis  of  the  membrana  tympani.  If,  however,  the  attack 
cannot  be  aborted  and  goes  on,  certainly  we  may  by  these  same 
means  alleviate  or  stop  the  pain,  and  modify  the  course  of 
the  disease,  so  that  recovery  of  the  ear  will  usually  go  on  step 
by  step  with  the  general  convalescence,  and  the  patient  will  not 
barely  recover  of  the  exanthem,  to  suffer  the  horrors  of  chronic 
suppuration  of  the  middle  ear.  All  that  writers  on  aural  sur- 
gery ask  that  general  practitioners  shall  do  in  cases  of  acute 
inflammation  of  the  middle  ear,  occurring  in  the  exanthemata, 
is,  that  they  treat  them  as  they  would  the  same  disease  occurring 
independently. 

The  practitioner  who  looks  through  the  generally  excellent 
works  on  the  diseases  of  children,  will  be  painfully  impressed 
with  the  fact,  that  very  little  attention  is  given  to  the  common 
complications  of  infantile  diseases  with  acute  catarrh  and  sup- 
puration in  the  ear. 

The  course  of  a  case  of  acute  aural  catarrh,  promptly  treated 


292  ACUTE  CATARRH— TREATMENT. 

in  the  manner  that  has  been  outlined,  usually  ends  in  complete 
recovery,  with  integrity  of  the  structure  and  .functions  of  the 
ear.  In  less  favorable  cases  suppuration  occurs ;.  but  this  is 
usually  tractable,  and  even  then  the  organ  may  be  restored  to 
complete  usefulness. 

It  is  unfortunately  true,  however,  that  an  acute  catarrhal  in- 
flammation of  the  middle  ear,  even  under  judicious  management, 
may  go  on  to  be  a  suppurative  one,  from  which  death  may  occur 
from  extension  of  the  inflammation  to  the  brain.  More  will  be 
said. of  this,  however,  in  the  chapter  upon  acute  suppuration. 

It  is  sometimes  stated  that  the  treatment  as  described  in 
the  preceding  pages  is  too  heroic,  and  that  milder  means  than 
leeches,  paracentesis,  scarifications,  an  incision  down  to  the 
periosteum  of  the  mastoid,  may  be  employed,  not  only  with 
safety,  but  with  benefit  to  the  patient.  The  use  of  leeches  has 
been  especially  objected  to,  on  account  of  the  local  irritation 
and  even  inflammation  they  are  said  to  frequently  cause.  Par- 
acentesis of  the  drum-head,  it  is  said,  is  a  dangerous  operation, 
and  often  performed  unnecessarily,  and  so  forth.  To  all  this,  I 
can  only  say  that  acute  catarrh,  or  acute  suppuration  of  the 
middle  ear,  are  serious  and  rapidly  progressing  diseases  that 
admit  of  no  temporizing,  of  no  delays  in  active  antiphlogistic 
treatment.  I  have  not  been  speaking  of  subacute  inflammatory 
affections,  of  neuroses  in  hysterical  and  anaemic  subjects,  but 
of  a  sthenic  inflammation,  with  its  pain  and  its  possibilities  of 
rapid  advance  from  the  tympanic  cavity  to  the  membranes  of 
the  brain,  to  the  general  circulation,  or  when  its  progress  takes 
a  more  favorable  turn,  to  the  membrana  tympani.  To  combat 
this  disease,  only  local  antiphlogistic  treatment  will  be  of  avail. 
Those  who  wish  to  arrest  pain  quickly,  to  prevent  dangerous 
consequences  from  an  extension  of  an  inflammatory  process, 
will  find  the  active  treatment  that  has  been  here  described 
will  not  disappoint  their  expectations.  Some  of  the  arguments 
against  the  means  now  in  vogue  among  the  modern  otologists, 
have  been  based  on  the  incorrect  assumption  that  they  are  em- 
ployed in  mild  cases  when  less  active  means  will  be  more  agree- 
able, and  equally  efficacious.  I  have  been  careful,  however,  as 
I  believe,  to  show  that  local  blood-letting,  paracentesis,  and  cut- 
ting down  to  the  periosteum,  with  confinement  to  a  room,  are 
chiefly  to  be  employed  in  severe  cases.  That  an  acute  inflam- 
mation of  the  middle  ear  is  a  severe  case,  certainly  no  one  will 
deny  who  has  been  called  to  treat  it,  or  who  has  unfortunately 
experienced  it. 

I  believe  as  fully  as  any  of  my  professional  brethren,  in  the 
natural  course  of  diseases,  which  it  is  often  better  not  to  attempt 


SUB-ACUTE   CATARRH.  293 

to  check  ;  in  the  vis  medicatrix  naturce  ;  in  the  danger  of  doing 
too  much  for  many  cases,  but  the  disease  now  under  considera- 
tion is  one  which  I  believe  from  a  long  and  large  experience  can 
only  be  successfully  combated  by  what  are  known  as  local  anti- 
phlogistic means,  among  which  leeches  and  the  warm  douche 
take  the  first  position. 


SUB-ACUTE  CATARRH  OF  THE  MIDDLE  EAR. 

There  is  a  variety  of  catarrh  of  the  middle  ear,  very  common 
in  young  persons  and  in  children,  although  it  also  occurs  in 
adults,  which  differs  in  so  many  respects  from  the  ordinary  type 
of  acute  catarrh,  that  it  seems  to  require  a  more  extended  notice 
than  the  references  that  have  been  made  to  it  in  discussing  the 
latter-named  affection.  I  have  ventured  to  term  this  affection 
sub-acute  catarrh  of  the  middle  ear.  It  has  many  of  the  symp- 
toms of  the  truly  acute  form.  The  absence  of  pain  is  the  chief 
distinguishing  mark  by  which  it  is  separated  from  the  latter 
form.  Some  authors,  judging  from  their  statistics,  have  classi- 
fied it  under  the  head  of  chronic  aural  catarrh.  Others  classify 
it  among  acute  affections.  While  the  former  view  may  not  be 
strictly  incorrect — for  the  affection  that  I  am  about  to  describe, 
may  last  for  months,  and  run  into  the  strictly  chronic  form — it 
has,  in  my  opinion,  more  of  the  characteristics  of  acute  catarrh 
in  its  nature,  and  in  its  readiness  to  yield  to  treatment,  than  of 
chronic  inflammation. 

In  spite  of  some  adverse  criticism,  especially  by  German 
authorities,  I  think  we  ma>  justly  draw  a  distinction  between 
an  acute  and  a  sub-acute  affection.  If  we  do  so,  we  shall  be  less 
likely  to  fall  into  the  error  of  treating  all  recent  cases  of  catarrh 
of  the  middle  ear,  as  vigorously  as  we  do  those  that  only  differ 
from  them  in  being  attended  by  great  pain  and  injection  of  the 
drum-head.  Acute  catarrh  demands  vigorous  treatment,  while 
the  sub-acute  form  will  get  on  very  well  with  mild  measures. 

Symptoms. — The  subjective  symptoms  of  sub-acute  catarrh  of 
the  middle  ear  may  be  stated  as  follows  :  It  is  observed  that  the 
patient,  without  suffering  from  pain  in  the  ear,  or  if  so,  from 
pain  that  is  not  long-continued,  is  very  often  so  hard  of  hearing 
as  not  to  hear  ordinary  conversation.  Very  little  is  thought  of 
this  by  the  friends  of  the  patient,  or  perhaps  by  the  medical  ad- 
viser ;  but  the  trouble  recurs,  the  attacks  become  more  frequent, 
and  the  period  of  impairment  of  hearing  more  prolonged,  so 
that  school-life  is  seriously  interrupted.  The  general  health 
may,  or  may  not,  be  impaired.  I  have  seen  many  such  cases 


294  SUB-ACUTE   CATARRH. 

in  boys  and  girls  in  excellent  general  health,  as  well  as  in  the 
delicate  and  strumous. 

The  objective  symptoms  are  as  follows  :  The  pharynx  is  usu- 
ally in  a  thickened  or  granular  condition,  the  normal  secretion 
is  excessive,  and  it  may  be  changed  in  quality,  and  be  decidedly 
muco  purulent.  The  tonsils  may  or  may  not  be  hypertrophied. 
The  membrana  tympani  has  lost  its  normal  neutral  gray  color, 
and  is  of  a  pinkish  hue.  The  vessels  are  not  usually  to  be  traced 
upon  any  part  of  it.  It  may  be  exceedingly  brilliant.  The  light 
spot  is  usually  absent,  or  is  smaller  than  usual ;  a  fact  which 
shows  that  the  drum-head  is  sunken  inward.  The  experiments  of 
Magnus,  which  have  been  described  in  the  tenth  chapter,  show 
that  any  excessive  pressure  which  pushes  the  drum-head  inward 
lessens,  or  if  the  pressure  be  great  enough,  obliterates  the  light 
spot.  The  hearing,  as  tested  by  the  watch,  is  found  to  be  very 
much  impaired,  and  only  such  conversation  as  is  addressed  to 
the  patient,  with  his  face  toward  the  speaker,  is  heard. 

This  impairment  of  hearing  in  children  is  very  often  attrib- 
uted to  ''absent-mindedness"  by  parents,  and  to  '"stupidity"  by 
teachers.  Children  are  not  usually  absent-minded,  and  when 
they  are  stupid,  there  is  always  a  cause,  which  should  be  traced 
out,  and  the  poor  child  not  treated  as  if  it  were  responsible  for 
the  disease  that  has  rendered  it  so.  Again  and  again,  will  the 
practitioner  find  that  he  is  obliged  to  correct  the  false  ideas  of 
parents  and  teachers,  who  do  not  know  that  children  always  pre- 
fer to  hear,  if  they  can.  Malingering  as  to  deafness  is  a  de- 
ception which  children  rarely  understand,  and  which  they  can 
never  successfully  maintain.  A  child  that  does  not  habitually 
answer  at  once  when  addressed,  should  be  at  once  carefully  ex- 
amined as  to  its  hearing  power,  before  it  is  scolded  for  absent- 
mindedness. 

Treatment. — It  is  apt  to  be  the  case,  that  proper  hygienic 
rules  have  not  been  observed  in  the  management  of  such  young 
patients.  They  have  been  allowed  to  eat  and  drink  food  im- 
proper for  growing  persons  ;  for  example,  tea  and  coffee,  pastry 
and  so  forth,  to  the  greater  or  less  exclusion  of  simpler  and 
more  nutritious  substances,  and  thus  a  capricious  state  of  the 
appetite  has  been  induced.  In  the  case  of  boys,  frequent  and 
prolonged  bathing  or  swimming,  of  which  ducking  the  head 
under  water  forms  the  chief  part,  is  sometimes  found  to  cause 
or  increase  the  impairment  of  hearing.  The  regulation  of  the 
diet  of  such  patients,  the  wearing  of  flannel  next  the  skin,  the 
abstaining  from  any  habits  which  may  be  recognized  as  pre- 
disposing to  inflammation  of  delicate  structures,  building  up  of 
the  system  by  a  proper  therapeutic  course,  such  as  the  exhibi- 


SUB-ACUTE   CATARRH.  295 

tion  of  cod-liver  oil  and  iron,  with  proper  attention  by  the  use 
of  gargles  to  the  mucous  membrane  pf  the  pharynx,  will  per- 
haps in  time  allow  Nature  to  relieve  these  cases  ;  but  the  im- 
pairment of  hearing,  which  is  the  most  striking  and  most  trou- 
blesome symptom,  will  be  the  last  one  relieved,  and  it  may  not 
be  relieved  at  all,  and  the  patient  grow  up  to  be  permanently 
hard  of  hearing.  We  have  at  our  hands,  however,  in  Politzer's 
mode  of  inflating  the  ears — a  method  of  treatment  that  has  been 
fully  described  in  the  second  chapter— a  means  of  instantly  im- 
proving the  hearing,  and  thus  of  removing  the  most  embarrass- 
ing symptom  in  an  instant. 

The  wonder  and  joy  depicted  on  a  little  patient's  face  when 
the  world  of  sound  opens  to  him  again,  after  the  air  has  once 
entered  the  Eustachian  tubes  and  tympanic  cavities,  is  some- 
thing very  pleasant  to  see.  In  the  absence  of  the  air-bag,  a  bit 
of  india-rubber  tubing  inserted  in  one  nostril,  the  other  being 
closed,  through  which  air  is  blown  from  the  lungs  of  the  sur- 
geon, will  do  very  well.  Indeed,  where  the  subjects  are  very 
young,  I  prefer  this  method,  which  is  Mr.  James  Hinton's  adap- 
tation of  Politzer's  principle.1 

The  pathological  changes  in  these  cases,  which  cause  the 
impairment  of  hearing,  are  probably  in  some  cases  simply  plug- 
ging of  the  faucial  orifice  of  the  Eustachian  tube,  in  others  of 
the  calibre  of  the  tube  and  the  tympanic  cavity  by  mucus.  Struc- 
tural changes,  such  as  thickening  of  the  mucous  membrane, 
adhesive  bands,  rigidity  of  the  ligaments  of  the  ossicles,  and  so 
forth,  have  not  occurred.  Hence  I  would  not  class  these  cases 
among  those  of  chronic  catarrhal  inflammation. 

It  is  probable  also  that  the  mobility  of  the  ossicles  is  inter- 
fered with  in  some  cases  by  the  accumulated  mucus  as  well  as 
by  the  swelling  of  the  articulations.  The  restoration  of  the  nor- 
mal vibrations  of  the  chain  of  bones,  and  the  removal  of  the  mu- 
cus explain  the  sudden  increase  of  hearing  power  by  inflation. 

I  append  three  cases,  two  of  which  have  been  before  pub- 
lished;2 but  I  have  been  able  to  follow  them  up,  and  note  that 
the  recovery  was  perfect.  I  again  publish  them,  with  an  addi- 
tional one  of  the  same  character.  The  cases  are  very  common, 
and  it  is  not  therefore  for  their  rarity  that  they  are  inserted,  but 
that  they  may  perhaps  teach  how  much  may  be  done  to  instantly 
relieve  this  form  of  disease.  The  practitioner  who  ignores  the 
ear  will  certainly  pass  by,  among  these  cases,  many  which,  if 
properly  examined  and  treated,  would  add  very  much  to  his 
reputation,  and  increase  his  power  of  doing  good. 

1  Professor  Hermann  Scliwartze  claims  priority  in  tliis  procedure. 
5  American  Journal  of  the  Medical  Sciences,  vol.  vii. ,  p.  64. 


296  SUB-ACUTE   CATARRH — CASES. 

CASES, 

CASE  i. j\  s.  B ,  aged  sixteen,  New  York,  September  1, 1865.  Has  been 

deaf  at  times  for  a  number  of  years,  and  for  the  last  summer  persistently  so.. 
His  general  condition  is  fair;  is  well  developed.  The  tonsils  had  been  so  much 
hypertrophied  as  to  impede  respiration  ;  but  they  were  removed  previous  to  his 
coming  under  my  observation.  The  pharynx  secretes  excessively,  as  well  as  the 
nasal  mucous  membrane.  There  are  numerous  granulations  scattered  over  the 
pharynx.  The  membranae  tympani  are  pinkish,  brilliant  in  appearance.  The 
light  spot  is  elongated.  The  watch  is  heard  about  six  inches  from  each  auricle. 

Politzer's  method  was  practised  three  or  four  times,  when  the  hearing  dis- 
tance extended  to  sixteen  inches  on  the  right  side,  and  ten  on  the  left.  A  gargle 
containing  iodine  and  brandy  was  ordered  to  be  used  twice  a  day.  He  was  also 
to  practice  Politzer's  method  twice  a  week,  in  connection  with  the  iodine  inhaler. 
The  patient  continued  to  improve,  and  at  the  present  writing,  April  20, 1866,  the 
treatment  has  been  abandoned,  the  hearing  power  being  nearly,  if  not  quite 
normal.  The  patient  goes  to  school  every  day.  He  was  seen  by  me  for  some 
weeks  once  a  week,  while  his  father,  who  is  a  distinguished  physician  of  this 
city,  carried  out  the  treatment  at  home,  which  consisted  in  the  use  of  the  gargle, 
inflating  the  middle  ear  by  Politzer's  method  once  in  three  or  four  days,  with 
attention  to  the  general  health.  1890.— The  patient  is  now  a  practitioner  of  med- 
icine, and  has  no  impairment  of  hearing. 

CASE  II. — Girl,  aged  sixteen,  at  Eye  and  Ear  Clinic  in  University  Medical 
College,  March  28,  1866.  Has  not  heard  ordinary  conversation  for  years,  and 
has  been  very  much  embarrassed  in  swallowing  and  breathing,  on  account  of 
enlarged  tonsils ;  general  condition  is  fair ;  the  voice  is  extremely  nasal ;  only 
hears  when  addressed  in  a  loud  tone  of  voice ;  the  watch  is  heard  two  inches  on 
the  right  side,  one  inch  on  the  left ;  membranse  tympani  present  nothing  strik- 
ing in  appearance,  except  that  they  are  quite  brilliant ;  the  tonsils  are  excessively 
hypertrophied.  The  use  of  Politzer's  method  immediately  improved  the  hearing 
somewhat,  which  improvement  lasted,  according  to  the  patient's  statement,  about 
a  day.  When  next  seen,  the  tonsils  were  excised  with  the  forceps  and  scissors, 
a  long  outgrowth  being  dragged  down  from  behind  the  soft  palate  on  the  right 
side,  which  must  have  pressed  upon  the  orifice  of  the  Eustachian  tube,  and  then 
the  iodized  air  was  driven  into  the  tube.  The  hearing  distance  became  two  feet 
on  the  right  side,  and  about  six  inches  on  the  left.  An  iodine  gargle  was  ordered, 
with  cod-liver  oil,  a  half  tablespoonful  to  be  taken  three  times  a  day.  The 
patient  is  now  under  treatment,  and  still  (April  26,  1866)  continues  to  improve, 
hearing  very  well,  with  no  trouble  in  respiration.  1872. — I  have  seen  this  patient 
several  times  since,  on  account  of  naso-pharyngeal  catarrh,  and  her  recovery  of 
hearing  proves  to  be  permanent. 

CASE  HI — Master (sent  to  me  by  Prof.  Fordyce  Barker,  January21, 1873), 

aged  fourteen.  This  boy  has  had  "a  cold,"  and  has  been  very  hard  of  hearing 
for  some  weeks.  He  is  in  excellent  general  health.  The  membranse  tympani 
present  nothing  particularly  abnormal.  The  pharynx  and  nostrils  are  secreting 
excessively.  Hearing  distance — right  ear,  -4^ ;  left  ear,  the  watch  is  only  heard 
when  laid  on  the  auricle.  He  was  seen  every  other  day  for  three  weeks,  when 
the  Eustachian  catheter  and  Politzer's  method  were  used,  while  a  gargle  of 


HEMORRHAGIC   INFLAMMATION.  297 

chlorate  of  potash  was  employed  at  home.  At  the  first  sitting  his  hearing  dis- 
tance was  brought  up  to  it  R.  E.,  -4a8-  left,  so  that  conversation  was  heard  with 
much  more  ease,  and  when  his  hearing  power  became  H  on  each  side,  and  was 
still  improving,  he  was  allowed  to  return  to  his  school. 

The  use  of  the  catheter  when  the  patients  will  submit  to  it, 
and  nearly  all  except  infants  will  do  so,  causes  the  action  of 
Politzer's  method  to  be  more  powerful.  It  probably  excites  the 
muscles  of  the  tube  to  more  vigorous  contraction.  When  chil- 
dren are  too  young  to  swallow  on  the  signal,  we  may  still  employ 
Politzer's  method,  by  putting  the  tube  in  one  nostril,  closing  the 
other  with  the  finger,  and  rapidly  forcing  in  the  air  in  spite  of 
the  child's  screams,  which  are  not  those  of  pain.  During  the 
swallowing  motion  that  the  little  one  involuntarily  makes,  air 
will  enter  the  tube.  It  is  highly  probable  that  infants  sometimes 
suffer  from  sub-acute  catarrh,  which  if  not  relieved  by  local  treat- 
ment passes  on  to  a  chronic  process,  which  ends  in  deaf-muteism. 
Where  any  doubt  exists,  the  little  patient  should  have  the  benefit 
of  it,  by  the  use  of  Politzer's  method,  which  can  do  no  harm,  and 
may  do  a  vast  deal  of  good.  The  existence  of  a  naso-pharyngeal 
catarrh  in  an  infant,  should  be  carefully  considered  by  the  attend- 
ing physician,  lest  it  result  in  one  of  the  tympanic  cavity,  and 
there  cause  changes  which  must  leave  permanent  impairment  of 
hearing. 

The  evil  consequences  of  neglected  colds  in  the  head  are  not 
always  sufficiently  appreciated  by  our  profession.  It  is  from  the 
children  who  suffer  frequently  from  this  affection,  that  the  large 
class  of  persons,  whose  hearing  is  greatly  and  permanently  im- 
paired, is  annually  recruited.  It  is  of  the  utmost  importance 
that  all  cases  of  impairment  of  hearing,  should  be  under  early 
supervision,  lest  a  permanent  defect  occur.  Inflation  of  the 
ear,  with  general  hygienic  means,  will  generally  relieve  these 
cases  promptly. 

HEMORRHAGIC  INFLAMMATION   OF   THE   MIDDLE   EAR. 

I  believe  I  was  the  first  to  report1  cases  of  acute  aural  catarrh 
which  had  an  unusual  course  and  termination — that  is  to  say, 
cases  in  which  the  course  was  very  acute  and  terminated  rapidly 
in  perforation  of  the  membrana  tympani  without  suppuration, 
but  with  quite  an  abundant  hemorrhage  through  the  drum- 
head. It  is  well  established  that  hemorrhage  into  the  middle 
ear  may  occur  in  the  course  of  kidney  disease,  just  as  from  the 
vessels  of  the  retina ;  but  the  two  cases  which  I  am  about  to  de- 

1  Transactions  of  the  American  Otological  Society,  1872. 


298  HEMORRHAGIC   INFLAMMATION. 

scribe  certainly  do  not  come  under  the  classification  of  hemor- 
rhage from  blood-vessels  made  atheromatous  by  renal  disease. 
They  are,  I  think,  to  be  considered  as  cases  of  acute  inflamma- 
tion of  the  lining  membrane  of  the  middle  ear,  in  which  the 
morbid  process  has  an  unusually  rapid  and  violent  course,  so 
that  not  merely  an  exudation  through  the  walls  of  the  vessels, 
but  an  actual  breaking  down  of  the  walls  themselves,  occurs ; 
there  is  then  such  an  accumulation  of  the  blood  in  the  cavity  of 
the  tympanum  that  rupture  of  the  drum-head  almost  iiecessarily 
follows.'  It  has  been  often  observed  that  in  many  cases  of  para- 
centesis  of  the  membrane,  for  the  relief  of  inflammation  of  the 
lining  membrane  of  the  drum  cavity,  blood  is  the  only  product 
that  escapes.  I  think  these  cases  are  analogous  to  those  which 
I  am  about  to  record,  and  that  they  serve  to  explain  them. 

CASE  I. — The  first  case  that  directed  my  attention  to  hemorrhage  through  the 
membrana  tympani,  as  a  consequence  of  acute  inflammation  of  the  middle  ear, 
•was  that  of  a  young  lady  of  rather  delicate  organization,  who  was  under  the  care 
of  Drs.  Agnew  and  Loring.  The  case  was  seen  in  consultation  with  the  latter- 
named  gentleman,  who  gave  me  the  history.  The  patient  was  deaf  from  what 
seemed  to  be  hypertrophy  of  the  membrane  lining  the  dram  cavity ;  the  mem- 
brana tympani  was  thickened,  sunken,  and  immovable  ;  she  was  treated  in  the 
usual  manner,  i.e.,  the  catheter  and  Politzer's  method  were  employed,  and  the 
attempt  made  by  them  to  force  the  drum-head  outward.  On  the  day  or  day 
before  I  saw  the  patient,  and  about  twenty-four  hours  after  the  catheter  and 
Politzer's  method  were  used,  she  was  seized  with  violent  pain  referred  to  the 
depth  of  the  ear ;  to  relieve  this,  paregoric  was  dropped  into  the  ear.  Dr.  Lor- 
ing and  I  saw  the  patient  in  the  evening ;  the  pain  had  then  somewhat  abated. 
On  examination,  I  found,  after  carefully  removing  the  fluid  that  had  been 
dropped  in,  that  the  membrana  tympani  was  ruptured,  and  that  blood  was  issu- 
ing from  the  pulsating  opening.  The  patient  recovered  after  an  erysipelatous  in- 
flammation of  the  auditory  canal  and  side  of  the  face.  I  did  not  see  her  again, 
but  Dr.  Agnew  examined  the  membrane  in  a  few  days,  and  could  find  no  rup- 
ture, and  no  trace  of  it. 

I  might,  perhaps,  be  slightly  in  doubt  as  to  the  occurrence  of  a  rupture  and 
hemorrhage  from  the  membrane  in  this  case,  had  I  not  seen  one  subsequently 
•which  was  very  similar,  and  where,  as  in  this  case,  no  suppuration  occurred  after 
the  rapture,  and  consequently  no  scar  remained.  The  presence  of  the  paregoric 
rendered  it  somewhat  difficult  to  determine  whether  the  fluid  in  the  rupture 
•was  blood  or  not ;  but  I  took  this  fully  into  consideration,  and  determined  that 
it  was. 

CASE  II. — This  occurred  in  a  gentleman  in  good  health,  of  forty-seven  years 
of  age.  He  smoked  excessively,  but  in  other  respects  his  habits  were  good.  He 
had  chronic  pharyngeal  catarrh,  but  it  troubled  kirn  very  little.  He  did  not 
remember  that  he  had  ever  had  earache  as  a  child  or  adult.  I  saw  him  on 
November  7,  1871.  His  history  was  as  follows:  About  10  o'clock  to-day,  he 
suddenly  experienced  a  severe  pain  in  his  right  ear.  The  pain  was  so  acute  that 
the  patient  was  obliged  to  leave  his  business  and  go  home.  The  treatment  con- 


HEMORRHAGIC   INFLAMMATION.  299 

sisted  in  the  instillation  of  sweet  oil  and  tincture  of  opium.  There  was  no 
relief,  however,  until  about  6  P.M.,  when  "a  loud  report  occurred  in  his  head," 
and  quite  a  free  hemorrhage-  occurred.  The  patient  thought  more  than  a  tea- 
spoonful  of  blood  escaped.  I  saw  him  a  few  moments  after  the  hemorrhage  had 
occurred.  The  pain  had  entirely  subsided  ;  the  membrana  tympani  was  perfo- 
rated in  the  anterior  and  inferior  quadrant,  and  a  small  quantity  of  dark-colored 
blood  was  about  and  in  the  opening,  while  the  membrane  was  pulsating  as  in  the 
former  case,  or  rather  the  blood  column  was  pulsating  in  the  cavity  of  the  tym- 
panum. This  patient  fully  recovered  without  any  suppuration  whatever.  The 
opening  healed,  and  the  hearing,  which  was  reduced  to  such  an  amount  as  to 
be  expressed  by  the  fraction  3^,  was  restored  to  a  normal  standard.  The  treat- 
ment consisted  in  the  careful  use  of  an  injection  of  tepid  water,  just  after  the 
occurrence  of  the  rupture,  with  the  subsequent  use  of  the  Eustachian  catheter, 
through  which  air  was  introduced,  and  Politzer's  method  of  inflating  the  drum- 
head. 

It  may  be  of  interest,  to  note  that  this  gentleman  died  some 
thirteen  years  afterward  of  cerebral  hemorrhage.  I  lately 
treated  a  gentleman  in  his  eighty-fourth  year,  who  suffered 
simultaneously  from  hemorrhagic  retinitis  and  hemorrhage  into 
the  middle  ear.  Absorption  of  the  blood  in  the  tympanic  cavity 
and  the  drum-head  was  followed  by  great  improvement  to  the 
hearing.  I  have  also  lately  seen  a  case  of  hemorrhage  into  the 
drum-head,  after  the  escape  of  fluid  into  the  tympanum  while 
gargling.  This  latter .  case,  however,  is  hardly  like  a  true  hem- 
orrhagic inflammation  of  the  middle  ear  which  I  first  described, 
and  which  is  now  generally  recognized.  Not  only  have  cases 
been  reported  by  eminent  authorities,1  but  in  one  hospital2  it  is 
reported  that  19  cases  have  been  observed  in  thirteen  years. 
Hemorrhagic  inflammation  of  the  middle  ear  is  usually  a  very 
tractable  inflammation  whose  violence  is  spent  with  the  hemor- 
rhage. The  history  of  such  cases,  especially  with  regard  to  the 
abatement  of  the  pain  as  soon  as  the  hemorrhage  occurs,  fur- 
nishes another  argument  for  an  early  perforation  of  the  drum- 
head, when  great  pain  is  experienced  and  the  drum-head  bulges. 

Since  the  publication  of  the  author's  cases  of  otitis  media 
hemorrhagica,  Dr.  Mathewson,  of  Brooklyn,  and  Dr.  Hackley, 
of  New  York,  have  also  observed  and  reported  at  a  meeting  of 
the  New  York  Ophthalmological  Society,  cases  of  acute  inflam- 
mation of  the  middle  ear,  in  which  hemorrhage  occurred  through 
the  membrana  tympani  before  any  pus  appeared.  Their  course 
was  quite  similar  to  that  of  those  I  have  related,  and  Dr.  Hack- 
ley's  case  occurred  in  a  young  woman  who  had  just  passed 
through  the  menstrual  period,  and  the  menses  reappeared  after 


1  Guide  to  the  Study  of  Ear  Disease,  by  T.  McBride,  M.D.,  p.  50.     Edinburgh,  1884. 
*  Brooklyn  Eye  and  Ear  Hospital  Report,  18S3. 


300  HEMORRHAGIC    INFLAMMATION. 

the  aural  hemorrhage  ceased.     Dr.  Pomeroy  also  reports  such 
a  case,  as  follows  : ' 

A  woman  of  fifty-five  was  seized  with  a  chill  at  ten  o'clock  in  the  evening, 
which  was  followed  by  fever  and  great  pain  on  the  left  side  of  the  head  and  in 
the  left  ear.  The  pain  continued  with  more  or  less  severity  for  five  days,  when 
Dr.  Pomeroy  saw  the  patient  and  found  the  niernbrana  tympani  intensely  red. 
Posteriorly  and  above  it  bulged  somewhat.  The  right  membrane  was  also  red, 
but  did  not  bulge.  The  left  membrane  was  opened,  and  after  inflation  the 
auditory  canal  was  nearly  filled  with  blood.  Two  days  after  the  membrane, 
which  seems  to  have  closed,  was  again  punctured  and  a  few  drops  of  blood 
evacuated.  The  patient  made  an  entire  recovery  without  suppuration  from  the 
ear.  The  patient  had  no  renal  disease  and  no  cerebral  symptoms. 


AURAL  HEMORRHAGE  IN  THE  COURSE  OF  BRIGHT'S  DISEASE. 

There  will,  perhaps,  be  no  better  opportunity  than  the  pres- 
ent of  alluding  to  those  hemorrhages  from  the  tympanic  vessels 
that  occasionally  occur  in  Bright's  disease.  Schwartze  reported 
such  a  case 3  in  1868. 

The  patient  was  a  non-commissioned  officer,  of  twenty-five  years  of  age,  who 
suffered  from  albuminuria,  with  retinal  hemorrhages.  There  was  also  enlarge- 
ment of  the  liver  and  spleen,  and  infiltration  of  the  lungs.  On  January  16, 
1868,  he  suddenly  complained  of  pain  in  his  right  ear,  which  had  been  previ- 
ously sound.  When  Dr.  Schwartze  saw  the  patient,  some  hours  after,  the 
membrana  tympani  was  of  a  bluish-red  color  and  devoid  of  concavity.  Some 
leeches  were  applied,  but  they  did  very  little  good.  The  next  day  the  mem- 
brane was  of  a  dark-red  color,  so  that  an  extravasation  of  blood  into  the  cavity 
of  the  tympanum  was  plainly  evident.  On  the  19th  there  was  an  abundant 
serous  discharge,  and  when  the  ear  was  cleansed  by  a  syringe,  a  small  blood 
coagulum  was  removed.  Anteriorly  and  below  there  was  a  perforation  in  the 
membrana  tympani,  about  as  large  as  the  head  of  a  pin.  In  the  afternoon  a 
whitish  mass  came  out  of  the  ear,  in  the  water  that  was  instilled  every  ten  min- 
utes. This  mass,  which  looked  like  a  fibrous  coagulum,  was  one  and  a  half 
inch  long,  and  two  lines  broad,  and  one-half  a  line  thick.  On  the  20th  an- 
other similar  mass  came  out,  and  on  the  22d  the  patient  died.  The  discharge 
from  the  ear  had  then  become  purulent. 

The  microscopic  examination  of  the  mass  removed,  when  it  was  not  quite 
fresh,  showed  an  extremely  fine  granular  mateiial,  mixed  with  numerous  scales 
of  epithelium.  The  post-mortem  examination  was  made  on  January  23d.  There 
was  great  hypertrophy  and  dilatation  of  the  left  ventricle.  Both  kidneys  were 
atrophied.  The  lungs  and  spleen  enlarged.  Pneumonia  of  both  lungs.  Re- 
tinitis  apoplectica,  with  retinal  detachment  on  both  sides. 

EAES. — Hemorrhagic  inflammation  of  the  membrane  lining  the  right  cavity 

1  Transactions  American  Otological  Society,  p.  86,  1875. 
z  Archiv  fur  Ohrenheilkuude,  Bd.  IV.,  p.  12. 


AURAL    HEMORRHAGE    IN    BRIGHT5  S    DISEASE.  301 

of  the  tympanum  ;  cavity  of  the  tympanum  filled  with  bloody  purulent  fluid. 
Membrana  tympani  greatly  reddened  and  swelled,  covered  by  a  thin  layer  of 
pus,  and  perforated  as  before  stated.  The  mucous  membrane  of  the  Eustachian 
tube  was  also  injected,  but  not  so  markedly  as  the  tympanic  cavity.  No  affec- 
tion of  the  labyrinth. 

In  the  left  ear,  of  which  .the  patient  did  not  complain  during  life,  the  cavity 
of  the  tympanum  was  also  filled  with  a  bloody  serous  fluid  ;  but  there  was  no 
inflammation  of  the  lining  membrane.  There  were  small  ecchymoses  on  the 
mucous  membrane  of  the  naso  pharyngeal  space.  The  mucous  membrane  of 
the  tube  was  injected,  and  mostly  so  at  the  faucial  orifice  of  the  tube. 

.  In  the  same  year  that  Schwartze  published  his  case,  Dr. 
Gouverneur  M.  Smith  read  a  paper  before  the  Acadejny  of  Med- 
icine,1 in  which  he  called  attention  to  the  fact  that  impairment 
of  hearing  was  at  times  one  of  the  symptoms  of  Bright's  dis- 
ease, and  a  symptom  that  could  not  be  explained  by  referring  it 
to  uraemia.  I  once  treated  a  case  of  obstinate  suppuration  in 
the  middle  ear,  in  a  man  of  sixty-one  years  of  age,  who,  al- 
though suffering  from  Bright's  disease,  of  which  he  died,  com- 
plained chiefly  of  neuralgic  pains  referred  to  his  suppurating 
ear,  for  three  or  four  months  prior  to  his  death.  I  have  now  no' 
doubt  that  the  renal  disease,  by  its  effect  upon  the  tympanic 
vessels,  was  the  cause  of  the  acute  suppuration  in  the  ear,  and 
that  if  I  had  seen  the  case  when  the  rupture  of  the  drum-head 
occurred,  that  I  would  have  found  it  hemorrhagic  in  its  nature. 
In  a  thesis  for  the  degree  of  Doctor  in  Medicine,2  Paul  Pis- 
sot  enumerates  three  forms  of  diseases  of  the  ear  as  arising  in 
Bright's  disease,  viz.,  tinnitus  aurium,  half  deafness,  and  com- 
plete deafness.  This  classification  is  so  unscientific  that  it  gives 
no  real  information.  The  only  important  part  of  this  thesis  is 
that  in  which  it  is  stated  that  Delacharriere  has  found  rupture 
of  the  membrana  tympani,  vascularity  along  the  handle  of  the 
malleus,  and  sclerosis  of  the  tympanum  in  cases  of  impairment 
of  hearing  occurring  in  Bright's  disease.  The  supposition  is 
then  made  that  the  aural  symptoms  may  be  due  to  an  oedema  of 
the  sheath  of  the  auditory  nerve.  This,  it  is  needless  to  say,  is 
a  purely  theoretical  view.  Even  the  occurrence  of  aural  symp- 
toms in  Bright's  disease  of  the  kidney  has  as  yet  attracted  but 
little  attention,  and,  as  far  as  I  know,  they  are  somewhat  rare, 
and  have  not  as  yet  been  accurately  studied.  A  certain  propor- 
tion of  the  few  that  seem  to  occur,  probably  depend  upon  hem- 
orrhage from  degenerated  blood-vessels  in  the  tympanic  cavity. 

1  On  the  Etiology  of  Bright's  Disease,  with  Remarks  on  the  Prophylaxis.     Trans- 
actions of  the  New  York  Academy  of  Medicine,  vol.  iii. 

2  American  Journal  of  Otology,  vol.  i.,  p.  136. 


302          VASCULAR  TLT:MORS  OF  MEMBRANA  TYMPAXI. 


VASCULAR  TUMORS  OF  THE  MEMBRANA  TYMPAXI. 

Todd,1  of  St.  Louis,  reports  a  case  of  somewhat  alarming 
hemorrhage  from  the  depth  of  the  auditory  canal,  after  the 
puncture  of  a  small  swelling  that  hid  the  membrana  tympani. 
The  patient  had  suffered  twenty-two  years  previously  from  sup- 
puration of  both  middle  ears.  As  a  result  of  this  disease,  his 
hearing  was  impaired,  and  he  had  a  throbbing  noise  in  his  left 
ear.  The  arterial  bleeding  was  stopped  by  a  tampon,  but  it  was 
renewed  on  removing  it,  and  the  sac  filled  with  blood  as  soon 
as  it  was  removed.  Under  the  use  of  a  compress  of  cotton  mois- 
tened with"  glycerate  of  tannin,  the  sac  was  found,  two  years 
later,  to  be  of  a  whitish  color  and  thickened.  It  was  about  the 
size  of  a  split  pea.  Dr.  Todd  was  not  able  to  see  the  membrana 
tympani  in  any  of  his  examinations.  It  is  possible  that  the 
hemorrhage  was  from  a  tumor  of  the  drum-head  or  tympanum, 
rather  than  from  one  having  an  origin  in  the  auditory  canal. 

Buck a  reports  a  case  of  vascular  growth  on  the  drum-head. 
In  the  posterior  superior  quadrant,  just  behind  the  short  process 
of  the  malleus,  was  found  a  bright  red  fleshy  mass,  about  a 
millimetre  or  a  millimetre  and  a  half  in  diameter.  It  was  soft 
and  freely  movable.  The  patient  was  a  lady  of  twenty-two 
years  of  age. 

•  I  am  now  treating  a  Sister  of  Charity  of  about  thirty -five 
years  of  age,  who  has  an  affection  of  the  right  middle  ear,  with 
a  vascular  growth  in  the  drum-head.  The  patient  was  first  seen 
in  the  spring  of  1883,  about  one  year  since.  Her  symptoms  were 
impairment  of  hearing  and  tinnitus.  A  red  growth  was  found 
to  involve  the  centre  of  the  membrana  tympani,  and  with  it  the 
handle  of  the  malleus.  It  formed  a  ridge  nearly  across  the 
whole  surface  of  the  membrane.  It  was  of  a  bright  red  color. 
I  incised  it  with  a  paracentesis  needle.  The  tissue  was  rather 
hard,  and  although  the  opening  was  full  and  bled  freely,  the 
tumor  did  not  fully  collapse.  Since  then  four  incisions  have 
been  made,  with  relief  to  the  tinnitus,  and  the  tumor,  although 
still  existing,  is  quite  small  and  is  less  vascular,  especially  at 
the  lower  extremity.  The  patient  has  also  been  treated  by  infla- 
tion of  the  tympanum.  The  incisions  into  the  tumor  were  for- 
merly followed  by  more  bleeding  than  is  now  experienced,  and 
the  patient  expresses  a  sense  of  relief  of  the  fulness  in  the  ear 
after  the  paracentesis.  This  tumor  seems  to  me  to  communi- 
cate with  the  tympanum.  It  may  be  a  growth  between  the  in- 

1  American  Journal  of  Otology,  voL  iv.,  p.  187. 
*  Treatise  on  the  Ear,  p.  372. 


VASCULAR    TUMORS    OF    MEMBRANA    TYMPANI.  303 

tegumentary  and  fibrous  la}7er.  The  tuning-fork  is  heard  better 
by  bone  conduction.  The  hearing  distance  varies  from  £  to  £•§, 
according  as  the  tympanum  is  free  from  mucus. 

Buck1  also  reports  a  second  case  of  vascular  tumor  of  the 
membrana  tympani.  This  case  was  seen  in  a  lady  of  sixty-five 
years  of  age,  who  consulted  Dr.  Buck  on  account  of  a  slight  im- 
pairment of  hearing,  that  had  existed  but  for  a  few  days.  In 
the  central  portion  of  the  posterior  superior  quadrant  of  the  left 
drum-head  was  a  dark  colored  tumor,  measuring  about  a  milli- 
metre at  its  base.  It  was  not  particularly  sensitive.  In  the  right 
there  was  a  similar  tumor,  in  a  corresponding  situation,  but  it 
was  smaller. 

Weir's 2  first  case  of  intra-tympanic  vascular  tumor,  is  very 
similar  to  the  one  of  which  I  have  just  given  a  sketch.  Re- 
peated incisions,  followed  by  cauterizations  and  inflation  of  the 
middle  ear,  finally  effected  a  cure.  Weir's  second  case3  was 
also  greatly  alleviated  by  incisions  and  cauterizations  with 
chromic  acid,  .but  the  patient,  a  colored  woman,  finally  died  of 
phthisis.  She  was  greatly  troubled  by  tinnitus,  which  was  usu- 
ally relieved  by  a  paracentesis. 

It  is  evident  from  the  history  of  these  cases  that  paracentesis 
or  incision  of  vascular  growths  of  the  drum-head,  or  tympanic 
cavity,  as  well  as  inflation  of  the  middle  ear,  are  generally 
indicated.  By  these  means  we  may  hope  ultimately  to  secure 
shrinkage  of  the  growths  and  a  return  to  a  normal  condition. 

The  causes  of  these  vascular  growths  are  not  evident  to  me. 
Those  related  by  Buck  appear  to  be  of  the  nature  of  naevi,  while 
those  of  Weir  and  myself  seem  to  be  consequences  of  inflam- 
mation of  the  tympanum. 

DIPHTHERITIC  INFLAMMATION   OF   THE   MIDDLE   EAR. 

The  origin  and  course  of  diphtheritic  inflammation  of  the 
middle  ear,  are  so  different  from  what  obtains  in  an  ordinary 
acute  inflammation  of  the  middle  ear,  caused  by  cold,  or  even 
from  this  disease  occurring  in  the  course  of  the  exanthemata, 
that  I  feel  justified  in  devoting  a  few  paragraphs  to  a  special 
discussion  of  it.  While  assisting  in  the  case  of  a  child  of  about 
eleven  years  of  age,  who  died  of  diphtheria,  and  about  whose 
hearing  before  his  illness  I  had  accurate  knowledge,  I  observed 
that  he  became  very  hard  of  hearing  in  the  course  of  the  diph- 

1  American  Journal  of  Otology,  vol.  iii.,  p.  283. 

2  Ibid.,  vol.  i.,  p.  120. 

3  Loc.  cit. 


304  DIPHTHERITIC    INFLAMMATION. 

theria  which  affected  the  fauces  and  nostrils.  The  impairment 
of  hearing  continued  as  long  as  he  lived.  It  may  have  been 
caused,  as  the  fuller  experience  of  other  writers  shows,  by  sim- 
ple catarrh  of  the  middle  ears,  or  by  the  formation  of  a  croupous 
membrane  in  the  Eustachian  tube  or  tympanum. 

The  principal  writers  upon  the  subject  of  diphtheria  of  the 
ear  are  Wendt,1  Wreden,2  and  Blau.3 

In  most  of  the  post-mortem  examinations  made  by  Wendt,  of 
diphtheritic  inflammations  of  the  ear,  there  was  merely  a  co- 
incidental hyperaemia  or  catarrh  of  the  tympanum,  in  connec- 
tion with  laryngeal  and  pharyngeal  diphtheria. 

Wreden,  however,  has  reported  18  cases  of  diphtheritic  inflam- 
mation of  the  middle  ear,  occurring  in  the  course  of  pharyngeal 
and  nasal  diphtheria,  complicated  with  scarlet  fever.  Diph- 
theritic inflammation  generally  causes  great  impairment  of  hear- 
ing when  it  involves  the  ear,  according  to  Wreden.  His  report 
indicates  that  the  internal  ear  was  also  affected  in  his  cases,  for 
the  tuning-fork  was  not  heard  through  the  bones.  The  drum- 
head was  half  destroyed  in  all  the  cases  examined  by  him.  The 
prognosis  is  worse  in  infants  than  in  older  children.  Wreden 
speaks  well  of  leeches  and  douches  of  solutions  of  tannin,  in  the 
treatment  of  diphtheritic  inflammation  of  the  middle  ear  and 
internal  ear. 

Dr.  0.  E.  Billington,  who  has  contributed  essentially  to  our 
knowledge  of  diphtheria,  by  a  report  of  a  large  number  of  cases 
to  the  New  York  Academy  of  Medicine,  informed  me,  and  also 
stated  in  a  public  discussion,  that  the  ear  had  not,  in  his  experi- 
ence, been  affected  in  diphtheria,  except  in  such  cases  as  were 
complications  of  scarlatina.  Billington  considers  the  difference 
between  the  two  diseases  to  be  so  marked,  as  to  make  it  a  diag- 
nostic point.  He  has  been  able  to  trace  cases  of  apparently 
simple  diphtheria  with  complicating  otitis,  back  to  a  scarlatinal 
origin.  He  thus  agrees  with  the  observations  of  Wreden  just 
quoted. 

Jacobi4  states  that  the  ear,  in  the  same  manner  as  the  eye, 
may  become  affected  with  diphtheria  by  continuity  with  the 
naso-pharyngeal  space.  He  says  a  slight  swelling  of  the  mucous 
membrane  of  the  orifices  of  the  Eustachian  tubes  in  children,  or 
a  moderate  diphtheritic  deposit  may  close  them,  and  hardness  of 
hearing  be  the  result.  In  such  cases  the  patient  not  infrequently 


1  In  Schwartze's  Pathological  Anatomy  of  the  Ear. 

2  Monatsschrift  fur  Ohrenheilkunde,  No.  X.,  1868. 

3  Berlin.  Med.  Wochenschrift,  December,  1881,  p.  729. 

4  Treatise  on  Diphtheria,  p.  74. 


DIPHTHERITIC    INFLAMMATION.  305 

complains  of  intense  pain  behind  the  angle  of  the  jaw  and  ear. 
Jacobi  also  recognizes  the  fact,  that  perforation  of  the  drum 
membrane  may  result  from  diphtheritic  inflammation  of  the 
middle  ear. 

Wendt '  found  a  tubular  croupous  membrane  or  a  solid  cast 
in  the  cartilaginous  part  of  the  Eustachian  tube.  Once,  the 
membranous  formation  involved  both  tympanic  cavities  and  the 
antrum  and  cells  of  the  mastoid,  and  even  covered  the  ossicula. 
With  this  exception  Wendt,  found  only  hyperaemia  or  hemor- 
rhage in  the  osseous  parts  of  the  middle  ear. 

Kupper 2  and  Gottstein '  also  report  cases  of  diphtheritic  otitis. 
The  former  author  gives  an  account  of  a  post-mortem,  in  which 
it  was  shown,  that  croupous  inflammation  of  the  mucous  mem- 
brane of  the  tympanum,  and  of  the  tube  had  occurred  with  an 
intact  drum-head. 

Blau,4  of  Berlin,  reports  in  full,  a  case  of  diphtheritic  pan- 
otitis,  occurring  after  an  attack  of  scarlatina,  upon  the  heels  of 
which,  as  observed  by  Wreden  and  Billington,  the  diphtheritic 
pharyngitis  and  otitis  may  quickly  follow.  In  Blau's  case  the 
hearing  was  completely  gone.  When  he  first  saw  his  patient, 
neither  the  tragus  nor  mastoid  process  was  sensitive  to  press- 
ure. A  membrane  was  found  in  each  auditory  canal.  Paralysis 
of  the  facial  nerve  and  great  redness  of  the  membrane  of  the 
tympanic  cavity  soon  followed.  Periostitis  and  abscess  of  the 
mastoid  also  occurred.  Blau  was  not  able  to  follow  the  case 
to  its  termination.  He  used  a  douche  of  lime-water  very  fre- 
quently with  good  effect  in  the  removal  of  the  membrane.  It 
will  be  seen,  that  it  is  a  perfectly  well-established  fact,  that  a 
croupous  membrane  may  form  in  the  middle  ear,  during  diph- 
theria. It  is  also  true  that  the  labyrinth  may  be  involved.  The 
evidence  leans  toward  the  truth  of  the  view  of  Dr.  Billington, 
that  diphtheria  of  scarlatinal  origin  is  the  only  form  in  which 
otitis  occurs.  The  reader  is  also  referred  to  the  report  of  a  case 
in  the  next  chapter  of  an  adult  dying  from  meningitis  consecu- 
tive to  aural  disease,  in  which  a  croupous  membrane  was  found 
in  the  middle  ear. 

Of  147  cases  of  deaf-muteism  lately  examined  by  me,  not  one 
was  ascribed  by  the  family  or  friends  to  diphtheria.  It  is  prob- 
able that  the  cases  of  diphtheria  in  which  severe  otitis  occurs, 
are  generally  fatal. 


1  Quoted  by  Blau,  loc.  cit. 

*  Archiv  fur  Ohrenheilkunde,  Bd.  XL,  p.  19. 

3  Ibid.,  Bd.  XVII.,  p.  16. 

4  Berlin.  Wochensclirift,  loc.  cit. 
20 


306  DIPHTHERIA — CEREBUO-SPINAL    MENINGITIS. 

Diseases  of  the  middle  and  internal  ear  (panotitis — Politzer) 
occurring  in  the  course  of  diphtheria,  should  be  energetically 
treated,  if  the  general  condition  allows.  At  any  rate, the  mouth 
of  the  Eustachian  tube  should  be  freely  sprayed  with  lime-water, 
or  solutions  of  tannic  acid,  and  Politzer's  inflation  practised,  So 
that,  if  possible,  the  tympanum  may  be  ventilated,  and  the  tubal 
muscles  kept  at  work.  Poultices  over  the  mastoid  and  in  front 
of  the  auricle,  with  repeated  douches  of  the  auditory  canal,  are 
also  to  be  earnestly  recommended.  The  violence  of  the  aural 
symptoms  in  diphtheria  are  only  equalled  by  what  occurs  in 
severe  cases  of  scarlatina,  where  I  have  seen  the  course  so  vio- 
lent in  an  inflammation  of  the  tympanum,  that  the  drum-head 
and  ossicles  were  swept  away  a  few  hours  after  the  first  symp- 
toms appeared  in  the  f  aucial  extremities  of  the  Eustachian  tube. 
Urgent  as  the  general  symptoms  will  undoubtedly  be,  those  re- 
lating to  the  ear  should  not  be  left  unrelieved  if  possible  to  miti- 
gate them. 

ACUTE  DISEASE  OF  THE  MIDDLE  EAR  IN  CEREBRO-SPINAL  MENINGITIS. 

The  examination  of  deaf-mutes  shows  that,  according  to  the 
testimony  of  their  friends  and  attending  physicians  (see  chapter 
on  "  Deaf-Muteism  v),  many  of  them  became  deaf  while  suffer- 
ing from  cerebro-spinal  meningitis.  In  my  opinion,  the  chief 
seat  of  the  lesion,  in  a  majority  of  these  cases,  is  to  be  found  in 
the  middle  ear.  I  am  sorry  that  I  am  seldom  called  to  see  a 
case  of  acute  cerebro-spinal  meningitis,  but  when  I  am,  I  advise 
the  use  of  leeches,  blisters,  and  mercury  to  combat  the  forma- 
tion of  an  exudation  or  purulent  formation  in  the  middle  ear.  If 
I  may  venture  to  advise  my  professional  friends,  who  see  this 
disease,  accompanied  by  impairment  of  hearing  or  deafness,  I 
would  say,  treat  the  aural  affection  as  if  it  were  one  of  acute 
catarrh  of  the  middle  ear.  The  prognosis  as  to  the  hearing  will 
then  not  be  altogether  hopeless,  although  it  is  usually  so  consid- 
ered. That  the  disease  of  the  ear  is  commonly  situated  chiefly  in 
the  tympanum,  I  hope  to  be  able  to  prove  in  the  discussion  of  the 
causes  of  deaf-muteism  in  a  subsequent  chapter  of  this  volume. 


CHAPTER  XII. 

ACUTE  SUPPUKATION  OF  THE  MIDDLE  EAR. 

• 

A  Consequence  of  Acute  Catarrh. — Symptoms. — Causes. — Course. — Cases  of  Meningitis 

Consecutive  to  Acute  Catarrh  and  Suppuration. — Criticisms  upon  the  Modern  An- 
tiphlogistic Treatment. — Neurotic  Cases. — Treatment  and  Cases. — Acute  Serous 
Inflammation  of  the  Middle  Ear. 

ACUTE  suppuration  of  the  middle  ear  commonly  occurs  as  a 
direct  and  recognized  consequence  of  an  acute  catarrh  of  the 
same  part.  A  catarrhal  process  is  unchecked,  and  passes  on  to 
a  suppurative  one.  In  some  cases  the  catarrhal  inflammation  is 
unobserved— we  cannot,  however,  say  that  it  does  not  occur — 
and  the  first  intimation  of  any  morbid  action  given  by  the  ear  is 
a  discharge  of  pus  from  the  auditory  canal.  I  have  seen  several 
cases  where. the  patients  have  assured  me  that  the  first  idea 
that  they  had  of  trouble  in  the  ear,  was  the  moistening  of  £he 
canal  from  the  flowing  out  of  the  pus.  An  examination  of  the 
ear  in  such  cases  has  always  revealed  a  perforation  of  the  mem- 
brana  tympani.  We  probably  never  see  a  discharge  of  pus  from 
the  surface  of  the  auditory  canal,  without  previous  intimation, 
by  pain  or  swelling,  that  an  inflammation  of  the  part  had  oc- 
curred, while  this  may  occur  from  the  tympanum.  It  is  my 
belief  that  the  cases  of  sudden  and  painless  perforation  of  the 
membrana  tympani  are  nearly  always  preceded  by  some  pre- 
monitory symptoms,  such  as  pharyngitis,  feelings  of  fulness  in 
the  ear,  impairment  of  hearing,  and  so  forth  ;  but  that  the  fail- 
ure to  notice  them  is  usually  to  be  attributed  to  carelessness  in 
observation,  and  that  it  is  to  be  regarded  as  another  indication 
of  the  common  indifference  to  an  inflammation  of  the  ear,  when 
it  is  not  positively  painful. 

Then,  again,  there  are  cases  where  pain  is  felt  long  before 
the  pus  is  discharged,  but  where  it  is  mistakenly  referred  to 
some  other  part  of  the  body,  or  to  a  neuralgia,  instead  of  an  in- 
flammation. 

It  is  not  to  be  denied,  however,  that  there  are  cases  of  acute 
suppuration  of  the  middle  ear,  where  the  initial  symptoms  of 
swelling  of  the  lining  membrane  of  the  Eustachiaii  tube  and 


308  ACUTE    SUPPURATION — SYMPTOMS. 

cavity  of  the  tympanum,  are  so  quickly  passed  over,  in  a  few- 
hours,  or  even  minutes,  as  to  be  practically  unrecognizable. 

Such  a  course  of  the  disease  is  frequently  observed  in  phthi- 
sis pulmonalis,  where  a  membrana  tympani  will  sometimes 
break  down  from  an  accumulation  of  mucus  behind  it,  and  go 
on  to  suppuration  without  a  trace  of  pain. 

The  usual  origin  of  acute  suppuration  is  a  violent  one.  The 
severe  pain  of  acute  catarrh  is  unrelieved,  pus  is  formed  in  the 
cavity  of  the  tympanum,  the  lining  of  the  mastoid  cells  is  very 
much  distended,  the  outer  surface  of  the  process  becomes  redr 
tender,  and  painful,  the  head  throbs,  and  the  whole  system  is- 
seriously  disturbed.  In  young  persons  delirium  occurs,  and  in 
all  subjects,  who  have  acute  suppuration  of  the  middle  ear, 
there  is  general  febrile  excitement,  and  the  condition  of  the  pa- 
tient is  one  of  intense  suffering.  There  is  probably  no  more  se- 
vere pain  to  which  the  human  system  is  liable,  than  that  due  to 
the  distention  of  the  little  space  called  the  cavity  of  the  tympa- 
num by  mucus,  blood,  serum,  or  pus. 

Symptoms. — The  symptoms,  then,  of  this  disease  are  usually 
pain  in  the  ear  and  head,  fever,  with  impairment  of  hearing 
and  tinnitus.  The  membrana  tympani  also  exhibits  marked 
changes  in  appearance. 

But  the  pain  may  be  entirely  absent,  as  we  have  seen,  and 
yet  the  inflammatory  process,  because  it  is  sudden  in  its  origin, 
be  fairly  entitled  to  the  adjective  acute.  The  cases  of  the  pain- 
less form  of  acute  inflammation  in  persons  suffering  from  phthi- 
sis pulmonalis  before  alluded  to,  are  not  as  amenable  to  treat- 
ment as  the  more  acute  cases.  I  suppose  this  fact  is  partly  to 
be  attributed  to  the  failure  in  the  general  nutrition,  and  also  to 
the  contiguity  of  a  diseased  mucous  membrane,  which  is  con- 
stantly acting  as  an  exciting  cause  of  trouble  in  the  pharynx 
and  Eustachian  tube. 

The  membrana  tympani  has  usually  lost  its  naturally  trans- 
parent appearance  in  a  case  of  acute  suppuration.  It  has  a 
boggy,  sodden,  or  swelled  appearance,  and  has  none  of  its  nor- 
mal distinguishing  marks — the  light  spot  and  the  handle  of  the 
malleus.  Yet  this  is  not  always  the  case.  I  have  seen  cases 
where  the  transparency  of  the  drum  membrane  was  almost  un- 
impaired, and  the  accumulated  pus  and  mucus  which  were 
bulging  it  out,  could  be  seen  through  it.  In  one  case,  that  of 
a  young  lady,  I  found  pus  not  only  in  the  cavity  of  the  tym- 
panum, but  also  between  the  mucous  and  fibrous  layer  of  the 
drum-head.  The  pus  moved  when  the  head  was  moved.  She 
recovered,  with  perfect  hearing  power,  and  a  sound  membrana 


ACUTE    SUPPUKATION — SYMPTOMS.  309 

tympani,  without  an  artificial  or  spontaneous  perforation  of  the 
drum-head.  The  treatment  resorted  to  was  the  use  of  leeches, 
a  gargle,  and  Politzer's  method.  There  was  considerable  pain 
at  the  outset,  but  not  the  intense  pain  which  is  usually  one  of 
the  characteristics  of  acute  suppuration.  The  patient  visited 
my  office  daily  during  the  whole  course  of  the  disease,  which 
occurred  in  the  mild  weather  of  spring. 

It  is  possible  that  some  cases  of  so-called  abscesses  of  the 
membrana  tympani  should  be  regarded  as  examples  of  limited 
suppuration  in  the  tympanic  cavity.  I  have  not  as  yet  seen  any 
cases,  where  it  seemed  to  me  that  an  abscess  was  confined  to 
the  layers  of  the  drum-head,  without  any  communication  with 
the  cavity  of  the  tympanum  or  the  external  auditory  canal.  It 
should  be  added,  that  the  osseous  portion  of  the  bony  canal  is 
often  found  to  be  very  much  inflamed,  in  conjunction  with  the 
symptoms  in  the  membrana  tympani,  the  cavity  of  the  tym- 
panum, and  the  mastoid  cells.  I  may  be  pardoned  for  remind- 
ing the  student,  that  it  is  often  impossible  to  draw  the  line 
between  the  affections  of  the  three  parts  of  the  ear.  Their  ana- 
tomical connections  show  that  they  must  of  necessity  run  into 
each  other,  however  distinctly  they  may  be  separated  in  their 
origin.  It  is  rather  a  predominance  than  an  exclusive  localiza- 
tion of  symptoms  in  a  part,  that  gives  rise  to  an  exact  classifi- 
cation of  disease.  For  example,  an  otitis  media,  in  a  young- 
child,  may  very  readily  and  rapidly  pass  on  to  an  otitis"  interna, 
or  inflammation  of  the  labyrinth,  and  give  us  much  difficulty  in 
deciding  which  was  the  original  affection.  Politzer  has  given 
the  name  ofpanotitis  to  these  cases. 

Causes. — The  causes  of  acute  suppuration  of  the  middle  ear 
are  the  same  as  those  that  have  been  enumerated  in  the  chapter 
on  "Acute  Catarrh."  The  important  ones  are  comprised  in  ex- 
posure to  wet,  draughts,  and  cold — inflammation  of  the  naso- 
pharyngeal  mucous  membrane  being  the  usual  starting-point. 

The  violent  use  of  the  posterior  nares  syringe  in  an  acute 
or  subacute  catarrh,  will  also  in  very  rare  cases  set  up  acute 
suppuration  in  the  tympanic  cavity  ;  at  least  I  have  seen  it 
do  so  in  one  instance  as  follows  :  A  physician,  aged  twenty- 
seven,  had  suffered  for  years  from  chronic  naso-pharyngeal 
catarrh.  During  the  winter  of  1872,  he  was  attacked  with  acute 
coryza  and  pharyngitis.  He  had  once  used  the  nasal  douche  for 
a  similar  attack,  and  it  caused  such  severe  symptoms  that  he 
was  obliged  to  desist  from  it.  I  was  in  the  habit  of  using  the 
naso-pharyngeal  syringe  for  him  at  irregular  intervals,  in  order 
to  relieve  the  chronic  naso-pharyngitis  from  which  he  suffered. 


310  ACUTE    SUPPURATION — CAUSES. 

On  visiting  him  one  afternoon,  when  he  was  suffering  from  the 
acute  attack,  his  nostrils  felt  so  full  of  secretion  that  he  requested 
me  to  use  the  naso-pharyngeal  syringe,  which  I  did,  injecting  a 
lukewarm  solution  of  chlorate  of  potash.  The  bulb  of  the  instru- 
ment caused  some  gagging  as  it  came  in  contact  with  the  swelled 
wall  of  the  pharynx.  In  an  hour  or  two  he  was  attacked  with 
acute  aural  catarrh  of  the  left  side,  which,  in  spite  of  the  most 
energetic  treatment  by  means  of  leeches,  went  on  to  suppuration 
before  morning.  Under  appropriate  treatment  the  patient  recov- 
ered, with  a  sound  drum-head,  and  with  the  hearing  power  as 
great  as  before  the  attack. 

The  fact  has  already  been  mentioned  that  sea-bathing  some- 
times becomes  a  cause  of  acute  catarrh.  In  the  same  manner, 
want  of  caution  in  protecting  the  side  of  the  head  from  the  force 
of  the  waves,  or  the  canal,  or  nostrils  and  Eustachian  tube  from 
the  entrance  of  water,  may  produce  acute  suppuration. 

Scarlet  fever,  measles,  diphtheria,  tonsillitis,  bronchitis,  pneu- 
monia, typhoid  fever,  whooping-cough,  and  cerebro-spinal  men- 
ingitis, play  an  important  part  in  the  production  of  acute  aural 
disease,  and  usually,  except  in  pneumonia  and  cerebro-spinal 
meningitis,  the  suppurative  form  is  the  one  first  recognized,  al- 
though as  has  been  said,  there  is  probably  almost  always  an 
unobserved  stage  of  the  milder  variety  of  inflammation. 

Injuries  of  the  side  of  the  head,  and  of  the  membrana  tym- 
pani,  are  causes  of  acute  suppuration  of  the  middle  ear  of  a  very 
severe  nature.  This  subject  has,  however,  been  discussed  in  the 
chapter  on  "  Injuries  of  the  Membrana  Tympani." 

Course. — The  course  of  acute  suppuration  is  usually  violent 
until  perforation  of  the  drum-membrane  occurs  ;  when  it  gives 
way — at  times  with  quite  a  loud  explosion — relief  to  the  severe 
pain  is  usually  experienced.  If  no  measures  are  -taken  to  re- 
move the  accumulated  pus,  and  to  check  its  formation,  the  im- 
pairment of  hearing  will  continue,  although  the  pain  and  tin- 
nitus may  be  relieved,  and  we  shall  soon  have  a  case  of  chronic 
suppuration  of  the  middle  ear,  and  the  patient  be  liable  to  all 
the  fearful  consequences  of  this  disease.  In  rare  cases,  pus  may 
escape,  however,  into  the  Eustachian  tube,  and  the  case  go  on 
to  resolution  with  no  perforation  of  the  drum-head.  This  is 
more  apt  to  occur  in  children  than  in  adults. 

In  the  worst  event  of  all,  the  suppuration  may  extend  into  the 
brain  or  the  blood-vessels.  It  may  pass  through  the  thin,  and 
sometimes  porous  lamella  of  bone  which  forms  the  roof  of  the 
cavity  of  the  tympanum,  or  it  may  go  beneath  into  the  jugular 
vein,  and  thus  produce  blood-poisoning  or  pyaemia.  It  may  also 
extend  to  the  labyrinth. 


ACUTE    SUPPUEATION — COUKSE.  311 

The  mastoid  process  is  of  course  always  more  or  less  involved 
in  acute  suppuration,  or  even  in  acute  catarrh.  Its  cells  form> 
as  the  anatomy  shows  us,  an  integral  part  of  the  middle  ear. 
There  are  probably  but  few,  if  any,  cases  of  suppuration  that  are 
limited  to  the  tympanum.  Disease  of  the  mastoid  process  is  also 
a  dangerous  complication  ;  but  for  a  full  discussion  of  the  sub- 
ject, I  beg  to  refer  the  reader  to  the  chapter  upon  consequences 
of  chronic  suppuration.  Under  appropriate  treatment,  however, 
the  secretion  of  pus  usually  soon  ceases,  the  membrane  closes 
up,  the  hearing  is  restored,  and  scarcely  a  trace  is  seen,  either 
in  the  anatomical  structure  or  the  functions  of  the  organ,  of  the 
disease  which  has  raged  so  violently. 

With  a  want  of  logic  that  is  remarkable,  some  practitioners 
invite  suppuration  of  the  drum-head,  in  every  case  of  acute 
catarrh,  or  "pain  in  the  ear,"  and  then  declare,  that  nothing  can 
be  done  for  the  hearing  when  the  membrana  tympani  is  once 
perforated.  Our  aim  should  always  be  to  prevent  or  limit  sup- 
puration in  the  ear,  but  if  it  do  occur,  and  even  if  a  large  portion 
of  the  drum-head  be  swept  away,  we  may  usually,  if  the  ossicula 
be  left,  by  prompt,  energetic,  and  patient  treatment,  restore  it, 
and  with  it,  the  hearing  power. 

It  should  be  observed,  that  diffuse  inflammation  of  the  ex- 
ternal auditory  canal  is  often  a  troublesome  "complication  in  the 
course  of  an  acute  aural  suppuration  with  perforation.  It  is 
probably  caused  by  the  irritation  of  the  pus  in  the  auditory  canal, 
and  perhaps  in  some  cases  by  the  excessive  manipulation  for  the 
purpose  of  cleansing  the  ear.  Such  a  complication  is  sometimes 
embarrassing  and  distressing,  for  it  protracts  the  duration  of  the 
disease  very  much. 

Acute  catarrh  and  acute  suppuration  of  the  middle  ear  are 
exceedingly  amenable  to  judicious  treatment.  There  are  no  im- 
portant parts  of  the  body  which  more  certainly  in  the  large 
majority  of  cases  recover  from  serious  inflammations  than  those 
that  make  up  the  middle  ear.  Indeed,  it  should  not  be  forgot- 
ten, that  acute  catarrh  and  acute  suppuration  very  often  run 
their  entire  course,  and  end  in  perfect  recovery  with  no  especial 
treatment.  Any  one  who  is  in  the  habit  of  hearing  the  histories 
of  patients  and  of  examining  the  membrana  tympani,  soon  con- 
vinces himself  that  young  children  often  recover  from  acute 
suppuration  of  the  middle  ear  under  very  crude  but  not  meddle- 
some treatment,  received  from  nurses  and  parents.  This  be- 
comes an  important  consideration  in  the  physician's  treatment 
of  acute  inflammations  of  the  ear,  for  it  will  lead  him  to  a  wise 
conservatism  in  certain  cases,  and  a  healthy  skepticism  as  to  the 
value  of  drugs  which  therapeutic  enthusiasts  praise  so  highly 


312  MENINGITIS   FROM   AURAL   DISEASE. 

and  with  which  they  claim  to  avert  a  suppuration  process. 
There  are,  however,  painful  exceptions  to  the  rule  that  acute 
suppuration  of  the  middle  ear  is  under  proper  guidance,  usually 
a  tractable  and  not  fatal  disease.  In  1877,  I  attended  a  case  in 
which  meningitis  followed  acute  purulent  inflammation  of  the 
middle  ear.  Death  occurred  in  about  twenty-eight  days  from 
the  appearance  of  the  acute  aural  symptoms.'  The  history  of 
the  case  is  as  follows  : 

Meningitis  following  Acute  Purulent  Inflammation  of  the  Middle  Ear — Death  in 
about  Twenty-eight  Days  from  the  Appearance  of  the  Aural  Symptoms — Post-mor- 
tem Examination  of  the  Brain  and  Temporal  Bone. — On  March  23,  1877,  Mr.  A. 

H..B ,  aged  forty-one,  whom  I  had  treated  for  syphilitic  iritis  some  two 

years  before,  sent  for  me,  on  account  of  a  severe  pain  in.  the  right  ear.  I  found 
the  patient,  who  was  a  well-developed  man,  apparently  in  robust  health,  sitting 
up,  but  giving  evidences  of  great  pain.  The  pain  was  referred  to  the  depth  of 
the  right  ear.  There  was  a  profuse  discharge  of  blood  and  pus  from  the  audi- 
tory canal ;  blood  predominated,  however.  The  membrana  tympani  was  per- 
forated. The  outlines  of  the  ossicles  were  not  seen  on  account  of  the  swelling 
of  the  lining  membrane  of  the  tympanic  cavity  and  of  the  remains  of  the  drum- 
head. There  was  some  sensitiveness  of  the  tragus  and  auditory  canal,  but  no 
especial  tenderness  of  the  mastoid  process. 

The  patient  stated  that  on  a  return  from  a  visit  to  Memphis  and  Mobile,  or 
about  five  days  before,  he  had  a  bad  cold  in  the  head,  with  severe  neuralgic 
pains  in  the  same  region. 

Three  or  four  days  after  the  "neuralgia"  he  consulted  Dr.  Royal  Prescott, 
through  whose  courtesy  I  am  able  to  present  the  history  from  that  time. 

Dr.  Prescott  says,  in  a  note  to  me  :  ' '  Mr.  B came  to  my  office  on  the 

evening  of  March  20th,  complaining  of  pain  in  the  right  ear,  and  deafness  on 
the  affected  side.  He  thought  that  his  hearing  had  been  affected  for  some  time 
on  that  side.  On  examination  I  discovered  a  quantity  of  inspissated  cerumen, 
which  I  removed  by  gently  syringing  with  warm  water.  ...  I  inserted  a 
few  drops  of  warm  glycerine  and  morphine,  put  in  a  pledget  of  cotton,  gave  him 
an  anodyne,  and  directed  him  to  take  a  saline  cathartic.  He  came  in  on  the 
following  morning  and  reported  that  he  had  passed  a  tolerable  night,  that  the 
pain  was  somewhat  abated,  but  had  not  wholly  disappeared."  Dr.  Prescott  then 
ordered  an  infusion  of  opium,  and  directed  him  to  remain  in  the  house  for  a 
few  days. 

On  March  22d,  according  to  Dr.  Prescott's  note,  the  pain  had  increased, 
when  hot  fomentations  to  the  ear  and  an  anodyne  were  ordered.  The  patient 
exposed  himself  in  a  severe  storm  in  his  last  visit  to  Dr.  Prescott's  office,  and 
became  worse.  At  this  stage  I  saw  the  patient.  I  ordered  the  application  of 
two  leeches  to  the  tragus  and  the  warm  douche  every  hour.  My  associate,  Dr. 
E.  T.  Ely,  called  at  nine  the  same  evening,  and  found  him  so  comfortable  that 
a  hypodermic  injection  of  morphia  which  I  had  proposed  was  not  administered. 

On  the  24th,  the  patient  was  quite  comfortable  and  free  from  pain,  but  he  was 
very  restless  and  did  not  sleep  well.  He  said  that  liis  sleeplessness  was  not  on 

1  Medical  Record,  July  7,  1877. 


MENINGITIS.  313 

ticcount  of  pain  in  the  ear,  but  on  the  25th  two  more  leeches  were  applied.  The 
discharge  from  the  meatus  continued  to  be  very  abundant  and  bloody.  The 
warm  douche  was  continued,  and  bromide  of  potassium  was  given  at  night.  Oil 
the  26th  there  was  no  pain  in  the  ear,  and  no  especial  tenderness  about  it,  but 
his  head  was  very  uncomfortable  and  restless.  The  patient's  tongue  was  heavily 
furred,  his  pulse  96,  and  temperature  101°.  He  was  sleepless  and  without  ap- 
petite. Cerebral  hypersemia  was  diagnosticated,  and  ten  grains  of  calomel  were 
ordered  at  11  P.M.  From  the  28th  to  the  morning  of  the  30th  the  symptoms 
•were  about  the  same.  By  the  aid  of  morphia  tolerable  sleep  was  secured,  but 
the  patient  showed  great  anxiety  and  discomfort.  On  that  morning,  at  my  re- 
quest, Dr.  Lewis  Fisher  saw  him  in  consultation,  and.  continued  to  see  the 
patient  with  me  until  his  death.  Dr.  Fisher  concurred  in  the  diagnosis,  and 
inasmuch  as  the  patient  had  suffered  from  syphilis,  he  suggested  the  use  of 
iodide  of  potassium  in  addition  to  the  warm  douche  and  morphine.  On  March 
31st  the  patient  had  a  severe  chill  at  noon,  which  lasted  for  an  hour,  and  which 
was  not  followed  by  sweating.  The  temperature  was  100°  at  about  12  noon  ; 
at  9^  P.M.,  103f  °.  The  patient  stated  that  he  never  had  had  a  malarial  attack, 
although  he  had  spent  much  of  his  life  in  a  malarious  country.  The  formation 
of  pus  was  supposed  by  Dr.  Fisher  and  myself  to  be  indicated  by  this  chill. 
There  was,  however,  no  tender  spot  about  the  ear,  and  there  seemed  no  chance 
of  getting  at  the  abscess,  if  one  was  forming.  There  continued  to  be  a  free  dis- 
charge from  the  meatus.  We  therefore  decided  to  administer  quinine,  as  an 
antipyretic.  We  accordingly  gave  him  twenty  grains  of  sulphate  of  quinine  and 
thirty  grains  of  bromide  of  potassium,  following  it  up  in  four  hours  after  with 
fifteen  grains  of  quinine.  On  April  1st  the  patient  appeared  much  better.  His 
temperature  was  98°,  his  pulse  72,  and  there  was  no  pain  in  the  ear,  and  scarcely 

any  in  the  head.  The  quinine  treatment  was  kept  up.  Mr.  B began  to  sit 

up  and  converse  on  business  matters,  and  became  very  cheerful,  although  we 
had  given  him  a  gloomy  prognosis  immediately  after  the  occurrence  of  the  chill. 
He  did  not,  however,  sleep  quite  as  well  as  a  convalescent  should,  and  on  April 
12th  he  suddenly  complained  of  severe  pain  in  his  right  knee-joint,  and  his  tem- 
perature ran  up  to  103^°.  He  slept  scarcely  at  all ;  he  also  complained  of  pain 
in  his  head,  which  was  not  localized.  The  discharge  from  the  ear  diminished 
very  much.  The  pain  in  the  knee  disappeared  in  about  twenty-four  hours,  and 
occurred  with  great  severity  in  the  back  and  left  thigh.  The  mastoid  process 
was  cut  down  upon  on  the  9th  or  10th,  but  no  disease  of  the  bone  or  periosteum 
was  detected.  On  the  15th  the  temperature  was  103|°,  the  pulse  84,  and  a  low 
muttering  delirium  occurred  at  intervals.  Professor  John  T.  Metcalfe  saw  the 
patient  on  this  day,  and  gave  his  opinion  that  it  was  a  case  of  cerebral  disease 
extending  from  the  ear,  and  although  he  regarded  the  prognosis  as  very  un- 
favorable, suggested  the  use  of  mercurial  inunctions  and  iodide  of  potassium, 
with  a  very  faint  hope  that  syphilis  was  causing  some  of  the  symptoms.  On  the 
16th  the  patient  was  scarcely  ever  conscious,  his  temperature  continued  at  104° 
to  104£°,  and  on  the  morning  of  the  17th  he  quietly  died. 

The  autopsy  was  made  by  Dr.  W.  D.  Spencer,  five  and  one-half  hours  after 
death. 

Head. — The  bones,  except  the  right  temporal  bone,  were  normal.  The  dura 
mater  was  normal.  The  sinuses  were  filled  with  dark,  soft  coagula. 

Brain. — The  vessels  on  the  surface  were  markedly  hypersemic.  The  vessels 
at  the  base  appeared  normal.  In  the  meshes  of  the  pia  mater,  most  markedly 


314  MENINGITIS   FKOM   AURAL   DISEASE. 

at  the  base,  and  equally  on  both  sides,  was  seen  quite  an  extensive  fibrino-puru- 
lent  exudation,  which  was  thicker  along  the  course  of  the  larger  vessels ;  this 
exudation  extended  anteriorly  to  the  surface  of  the  right  hemisphere,  when  it 
was  more  sero-purulent.  The  lateral  ventricles  were  markedly  dilated  and  filled 
with  blood-stained  serum.  The  brain  substance  was  firm  and  markedly  hyper- 
femic,  otherwise  normal  as  far  as  examined.  The  connective  tissue  posterior  to 
the  external  ear  and  coating  the  mastoid  bone  was  somewhat  oedematous.  (This 
was  the  site  of  the  incision  down  to  the  bone,  an  incision  that  was  kept  open 
by  tents.) 

Description  of  the   emporal  bone  : 

Mastoid. — There  are  two  discolored  spots  on  a  line  running  outward  from  the 
meatus  auditorius  externus. 

Petrous  portion. — Just  in  front  of  the  elevation  made  by  the  semicircular 
canals  the  bone  is  exceedingly  soft.  In  washing  it  was  broken  down,  and  the 
whole  structure  here,  or  the  roof  of  the  tympanic  cavity,  is  found  to  be  in  a 
state  of  ulceration.  An  opening  through  the  squamous  portion  of  the  bone,  or 
in  the  temporal  fossa  would  be  about  on  a"  line  with  this  ulcerated  point. 

Lateral  sinus. — The  bony  wall  of  this  venous  canal  is  discolored,  thinned, 
and  softened  throughout  about  one-half  its  extent. 

Tympanic  cavity. — The  ossicula  are  intact,,  but  the  whole  of  the  rnerabrana 
tympani  is  gone. 

We  are  all  familiar  with  cases  of  meningitis  resulting  from 
disease  of  the  middle  ear  of  long  standing,  but  cases  of  this 
kind  following  acute  aural  disease  are  fortunately  more  rare. 
Indeed,  we  generally  expect  to  subdue  an  acute  inflammation  of 
the  ear,  if  we  are  able  to  treat  it  antiphlogistically  within  a  few 
days  of  the  outbreak  of  the  disease.  Nowhere  does  rational 
therapeutics  avail  more  than  in  acute  affections  of  the  ear.  In 
this  case  there  was  never  a  discharge  from  the  ear,  according  to 
the  patient's  statement,  until  a  few  hours  before  I  saw  him. 
The  affection  began  as  an  acute  otitis  media  catarrhalis,  with 
impaction  of  cerumen,  which  the  patient,  until  corrected  by  Dr. 
Prescott,  thought  was  a  facial  neuralgia — a  not  uncommon,  but 
dangerous  error.  It  ran  a  violent  course,  as  is  shown  by  the 
bloody  discharge  and  great  pain. 

The  purulent  process  in  the  middle  ear  extended  to  the  tissues 
of  the  roof  of  the  tympanic  cavity,  and  to  the  labyrinth  and  to 
the  membranes  of  the  brain,  where  the  hypersemia  soon  became 
an  exudative  inflammation  of  the  base,  extending  very  slowly 
to  the  upper  surface,  and  consequently  leaving  the  intellect  un- 
impaired for  a  long  time.  The  disease  of  the  bone  went  on 
slowly  at  the  same  time.  The  pyaemic  symptoms  are  explained 
by  the  disease  of  the  lateral  sinus.  The  circumstances  of  the 
patient — for  he  lived  in  a  crowded  boarding-house — were  not 
favorable  to  the  quiet  that  should  always  be  secured  for  a  pa- 
tient with  cerebral  hyperaemia,  and  I  fear  that  I  did  not  lay 


MENINGITIS. 


315 


stress  enough  upon  this  requisite  in  the  first  few  days.  My  sus- 
picions as  to  cerebral  hypersemia  were  somewhat  lulled,  how- 
ever, during  the  first  forty-eight  hours,  by  the  fact  that  the  pain 
in  the  ear  nearly  entirely  disappeared  from  the  first  application 
of  the  leeches.  The  only  part  of  the  case  that  now  seems  ob- 
scure to  me,  and  in  this  opinion  Dr.  Fisher  agrees,  is  the  reduc- 
tion of  the  temperature,  and  the  great  improvement  in  the  gen- 
eral condition  immediately  after  the  use  of  the  large  doses  of 
quinine.  We  gave  quinine,  as  has  been  intimated,  on  the 
shadow  of  a  hope  that  we  were  dealing  with  a  severe  case  of 


FIG.  82. — Showing  Disease  of  Bone  in  Case  of  Meningitis  following  Acute  Suppuration  of 
the  Middle  Ear.  a,  Caries  in  front  of  elevation  for  semicircular  canals  ;  6,  caries  of  lateral 
sinus  ;  c,  meatus  auditorius  internus. 

malarial  fever,  instead  of  one  of  abscess  of  the  brain  or  inflam- 
mation of  the  meninges.  With  a  diagnosis  of  either  of  the 
latter-named,  we  had  simply  to  sit  down  with  folded  arms  and 
await  the  dissolution  of  the  patient.  The  reduction  of  the  tem- 
perature immediately  followed  the  administration  of  the  quinine, 
and  each  day,  as  it  showed  a  disposition  to  rise,  the  same  rem- 
edy seemed  to  lower  it,  until  the  septica?mic  pains  set  in,  when 
it  utterly  failed.  Indeed,  so  well  was  the  patient  for  about  a 
week,  that  Dr.  Fisher  and  I  were  inclined  to  change  our  original 
diagnosis.  Such  a  lull  in  the  symptoms  of  cerebral  disease  re- 


316  MENINGITIS   FROM   AURAL   DISEASE. 

suiting  from  an  inflammation  of  the  ear,  is,  however,  not  with- 
out precedent. 

There  was  always  an  unbroken  bone  between  the  ulcerated 
tympanic  cavity  and  the  membranes  of  the  brain,  so  that  the 
fatal  inflammation  must  have  extended  through  some  of  the 
small  foramina,  which  abound  in  the  temporal  bone.  This  is  no 
new  pathological  observation,  since  it  has  long  been  known,  al- 
though not  always  remembered,  that  we  may  have  meningitis 
as  an  extension  of  aural  disease  without  the  occurrence  of 
caries. 

Another  case  of  this  unfortunate  series  was  reported  by  Dr. 
C.  S.  Merrill,'  of  Albany,  N.  Y.  Death  occurred  on  the  fourth 
day  after  the  origin  of  the  acute  inflammation  of  the  middle  ear. 

The  patient  was  a  book-keeper,  temperate  and  regular  in  his  habits  of  life. 
He  had  always  been  well,  but  for  two  or  three  weeks  he  had  been  a  little  debili- 
tated from  overwork.  On  November  7,  1877,  he  noticed  for  the  first  time  a  ful- 
ness in  his  right  ear.  He  consulted  his  family  physician,  who  sent  him  to  Dr. 
Merrill.  The  membrana  tympaui  was  found  congested,  and  the  hearing  on  that 
side  impaired.  The  ear  was  inflated  by  Politzer's  method,  and  the  family  phy- 
sician was  advised  to  apply  two  leeches  to  the  ear.  Dr.  Merrill  did  not  see  the 
case  again  for  two  days,  when  Dr.  Bigelow  sent  for  him.  It  was  then  stated  that 
the  leeching  had  entirely  relieved  the  condition,  so  that  all  feelings  of  fulness 
passed  away,  and  the  hearing  became  normal.  The  patient,  contrary  to  Dr. 
Bigelow's  advice,  resumed  his  office  duties.  But  on  the  9th,  at  5  o'clock  in  the 
morning  he  was  attacked  with  severe  pain,  and  Dr.  Bigelow  was  sent  for  on  the 
next  day  at  noon  and  found  the  pulse  160,  temperature  103|°,  respiration  28. 
The  patient  was  delirious.  The  membrana  tympani  was  bulging  and  greatly 
inflamed.  A  free  incision  of  the  membrane,  which  was  thick  and  resisting, 
evacuated  a  large  amount  of  pus.  The  next  day  the  local  inflammation  had 
greatly  subsided,  but  coma  supervened,  and  death  occurred  four  days  from  the 
first  manifestation  of  aural  symptoms.  The  post-mortem  examination  showed 
meningitis.  "  Pus  was  found  over  the  region  of  the  petrous  bone."  There  was 
perforation  through  the  roof  of  the  middle  ear,  and  underneath  the  dura  mater 
and  covering  the  surface  of  the  brain  there  were  a  few  drops  of  greenish-colored 
pus.  The  bone  was  perforated  by  two  or  three  small  openings.  There  was  no 
evidence  of  inflammation  of  the  internal  ear. 

Dr.  Merrill  remarks  :  "The  fatal  termination  of  the  case  was 
evidently  due  to  the  direct  extension  of  the  inflammation  to  the 
membranes  of  the  brain  through  the  roof  of  the  middle  ear, 
which  in  this  patient  was  cribriform  in  appearance." 

I  also  saw,  in  consultation  with  Dr.  Loring,  a  case  in  which 
death  from  meningitis  occurred  after  a  few  days  of  symptoms  of 
acute  inflammation  of  the  middle  ear.  This  patient,  however, 
Jiad  had  sub-acute  catarrh  of  the  middle  ear  at  various  times  dur- 


1  Transactions  of  the  American  Otological  Society,  vol.  iii.,  p.  29.     1882 


MENINGITIS.  317 

ing  the  two  years  preceding  the  attack  which  terminated  fatally. 
It  was  not  a  suppurative  case.  Dr.  Welch,  who  made  the  post- 
mortem examination,  regarded  it  as  a  croupous  inflammation 
of  the  middle  ear.  I  was  present  when  Dr.  Loring  made  a  large 
free  opening  in  the  membrana  tympani,  and  found  that  it  con- 
tained no  secretion.  The  dura  mater  was  normal  except  in  one 
situation.  That  over  the  roof  of  the  tympanic  cavity  and  the 
adjacent  portion  of  bone,  was  very  much  congested  and  showed 
"  numerous  small  red  points,  which  represent  punctate  hemor- 
rhages." The  roof  of  the  tympanic  cavity  was  found  extremely 
thin  and  translucent,  but  "it  was  not  carious.  The  mucous 
membrane  of  the  middle  ear  was  found  swelled,  softened,  of  a 
bluish-red  color,  and  coated  in  many  places  with  a  reddish-gray 
opaque  false  membrane,  averaging  about  one  millimetre  in  thick- 
ness. Punctate  ecchymoses  can  be  seen  in  the  swollen  mucous 
membrane,  but  there  were  no  coagula  of  blood  in  the  cavity  of 
the  tympanum."  The  swelling  and  exudation  were  most  marked 
on  the  membrane  of  the  roof  of  the  tympanum,  on  the  promon- 
tory and  entrance  of  the  Eustachian  tube.  There  was  also  exu- 
dation in  the  osseous  portion  of  the  tube.  The  ossicles  were 
movable,  the  labyrinth  and  auditory  nerve  were  sound.  There 
was  no  fibrinous  exudation  in  the  pharynx,  fauces,  or  air-pas- 
sages. After  a  microscopical  examination  Dr.  Welch,  gave  as 
his  opinion  that  the  case  had  been  one  of  otitis  media  crouposa 
with  consecutive  septo-meningitis.  The  ' '  consecutive  "  was  prob- 
ably placed  somewhat  in  doubt,  because  at  the  post-mortem  ex- 
amination it  was  not  easy  to  trace  the  starting-point  of  the  men- 
ingitis of  the  convexity  of  the  brain  from  the  right  middle  ear. 
The  yellowish  sero-purulent  exudation  in  the  sub-arachnoid 
space  and  meshes  of  the  pia  mater  covering  the  convexity  of 
the  cerebral  hemispheres,  "  was  rather  more  abundant  upon  the 
left  than  the  right  side."  ' 

Added  to  these  exceptional  cases  of  death  from  acute  inflam- 
mation of  the  middle  ear,  is  that  of  a  young  man,  who  was 
attended  by  my  associate  in  private  practice,  Dr.  Edward  T.  Ely, 
with  whom  I  saw  the  patient  in  consultation,  who  died  in  a  few 
days  from  consecutive  meningitis,  without  rupture  of  the  mem- 
brana tympani.  His  first  symptoms  were  from  the  ear,  and 
there  were  objective  appearances  of  acute  inflammation  of  the 
middle  ear.  Symptoms  of  meningeal  hypersemia  were  very  early 
in  appearance,  and  in  spite  of  active  treatment  he  soon  died  in  a 
comatose  state.  No  post-mortem  examination  was  made. 

The  reader  will  observe  that  the  thinness  of  the  bone  forming 


American  Journal  of  Otology,  vol.  iii.,  p.  126. 


318  ACUTE  SUPPURATION — TREATMENT. 

the  roof  of  the  tympanic  cavity  was  marked  in  two  of  the  fore- 
going cases.  As  has  been  pointed  out  by  all  the  recent  writers 
on  aural  surgery,  this  anomaly  is  not  uncommon,  and  where  it 
does  exist,  it  must  cause  a  peculiar  susceptibility  to  consecutive 
meningitis  from  disease  of  the  middle  ear.  Since  we  can  never 
know  beforehand  in  which  cases  this  anomaly  is  found,  and  while 
we  do  know,  that  in  young  children  the  bone  is  always  thin  and 
porous,  we  may  on  reflection  realize  the  possible  serious  char- 
acter of  any  case  of  acute  disease  of  the  middle  ear. 

I  can  add  another  case  of  death  from  acute  suppuration  of  the 
middle  ear,  which  occurred  in  my  practice  at  the  Manhattan  Eye 
and  Ear  Hospital.  In  this  case,  however,  the  rational  treatment 
was  undertaken  some  days  after  the  disease  had  fully  set  in, 
and  it  is  also  altogether  likely  that  the  fatal  termination  was 
hastened  by  the  patient's  bad  habits.  I  first  saw  the  young  man, 
who  was  the  victim  in  this  case,  when  he  was  pale  and  haggard 
from  pain  and  sleeplessness.  The  drum-head  was  bulging.  I 
punctured  it  and  evacuated  considerable  pus.  This  gave  great 
relief,  as  he  told  me  two  days  later,  when  he  again  appeared  at 
the  clinic.  His  whole  aspect  was  much  better,  and  he  told  me 
that  he  had  slept  well  for  two  nights.  He  died  in  a  few  days, 
just  after  a  drunken  debauch.  The  physician  who  saw  him 
informed  me  that  he  died  from  meningitis,  consecutive  to  the 
aural  trouble,  but  I  was  not  able  to  get  an  exact  account  of  the 
lesions,  although  the  death  was  investigated  by  the  Coroner, 
and  an  attempt  was  made  by  some  of  the  patient's  friends  to 
prove  that  his  death  was  caused  by  the  operation  (paracentesis 
of  the  drum-head),  which  secured  him  the  first  sleep  he  had  had 
for  some  days.  The  most  appalling  evidence  was  given  to  show 
that  the  "Doctors  murdered  him  by  running  an  instrument  into 
his  brain."  l 

Treatment. — The  moral  of  the  foregoing  is  plainly  to  be  read. 
An  acute  catarrh  or  suppuration  of  the  middle  ear  should  never 
be  lightly  estimated.  A  case  seen  early  in  its  course  will  usu- 
ally prove  very  tractable  and  respond  readily  to  treatment,  but 
if  left  to  itself  it  may  be  a  'serious  case.  The  first  step  in  the 
treatment  is  to  insure  quiet  and  freedom  from  care  for  the  pa- 
tient, if  an  adult.  Patients  with  acute  suppuration  should  usu- 
ally be  confined  to  their  rooms.  If  adults,  absolute  freedom 
from  business  or  domestic  employment  should  be  insisted  upon. 

1  The  medico-legal  reader,  may  possibly  be  interested  in  the  verdict  given  by  the 
Coroner's  jury  in  this  case.  The  following  is  a  copy  of  it:  "We  the  jury  come  to  the 

conclusion  that came  to  his  death  by  a  rupture  of  the  blood-vessels  of  the  small 

brain  or  with  some  instruments  used  by  doctors  unknown  to  the  jury." 


ACUTE  SUPPUEATION — TREATMENT.  319 

Each  case  should  be  watched  as  forming  a  possible  starting- 
point  for  cerebral  meningitis.  In  the  large  majority  of  cases 
such  a  deplorable  consequence  will  not  occur,  but  it  would,  I 
think,  be  much  less  frequently  observed,  were  each  patient  with 
acute  suppuration  carefully  guarded  from  the  exciting  causes 
of  cerebral  hypersemia,  from  the  beginning  of  the  aural  disease 
until  he  is  fairly  convalescing.  The  room,  or  ward  in  which 
such  a  patient  is,  should  be  kept  free  from  visitors,  prolonged 
conversation,  bright  light,  noise  should  not  be  allowed,  and  an 
attempt  should  be  made  to  secure  physical  and  mental  quiet. 
To  underrate  the  gravity  of  an  acute  suppuration,  or  even  an 
acute  catarrh  of  the  middle  ear,  is  to  invite  peril  to  life. 

I  have  seen  at  least  two  cases  where,  I  believe,  the  life  was 
lost,  because  the  patients  insisted  that  a  painful  ear  and  a  ten- 
der mastoid  process,  were  not  sufficient  causes  to  keep  them 
away  from  business  and  from  active  social  life. 

If  the  case  be  seen  in  the  earlier  stages — that  is,  when  the 
pain  is  still  present,  and  the  membrana  tympani  is  intact — two 
or  more  leeches  should  be  at  once  applied,  and  if  the  appearance 
of  the  membrana  tympani  indicate  that  it  is  about  to  rupture, 
or  if  the  pain  be  not  quickly  subdued  by  the  use  of  the  leeches, 
a  paracentesis  of  the  membrana  tympani  should  be  at  once  per- 
formed in  the  most  bulging  portion  of  the  membrane.  If  the 
mastoid  be  red,  tender,  and  swelled,  it  should  be  poulticed  thor- 
oughly and  well,  and  if  relief  be  not  apparent  in  twelve  hours, 
it  should  be  incised  down  to  the  bone,  except  in  the  case  of 
young  children,  where  the  more  yielding  nature  of  the  integu- 
ment and  the  periosteum  will  admit  of  some  delay.  If  the  mas- 
toid process  be  simply  red  and  tender,  but  not  swelled,  the  use 
of  leeches  and  poultices  will  probably  subdue  the  inflammation 
without  an  incision. 

The  ear  should  be  douched  very  often,  say  every  half  hour, 
with  lukewarm  or  hot  water,  by  means  of  a  fountain  syringe  or 
the  Fayette  douche,  the  temperature  of  the  water  being  deter- 
mined by  the  patient's  feelings.  This  procedure  the  patient  will 
usually  find  very  grateful.  In  case  of  the  absence  of  a  douche, 
warm  water  may  be  dropped  into  the  ear  from  the  sponge,  a 
procedure  as  old  as  the  time  of  Hippocrates.  A  douche  may  be 
extemporized  by  the  syphon  arrangement  of  a  bit  of  rubber 
tubing  in  any  kind  of  a  vessel  that  will  contain  water.  At  the 
same  time,  especially  if  the  weather  be  cold,  the  patient  should 
be  kept  in  his  room,  and  perhaps  in  bed,  while  pediluvia  and 
diaphoretics  are  employed. 

If  the  membrana  tympani  have  ruptured,  the  pus  should  be 
removed  at  least  twice  a  day,  by  careful  but  thorough  syringing. 


320  ACUTE  SUPPURATION — TREATMENT. 

The  quantity  of  pus  discharged  is  sometimes  enormous.  At 
the  same  time,  Politzers  method  of  inflating  the  ear  should 
be  practised.  This  latter  procedure  gives  no  pain  when  care- 
fully done,  i.e.,  when  the  bulb  is  not  too  vigorously  pressed.  It 
at  once  improves  the  hearing,  helps  to  cleanse  the  ear,  and  pre- 
vents the  formation  of  adhesions  in  the  cavity  of  the  tym- 
panum, and  gives  the  patient  hope  and  confidence. 

The  throat  should  be  kept  free  of  secretion  by  a  gargle.  The 
chlorate  of  potash  in  a  saturated  solution  is  the  one  I  usually 
use.  In  cases  of  scarlet  fever,  the  pharynx  will  require  the 
most  careful  and  energetic  treatment.  The  neck  should  be 
kept  warm  by  poultices,  and  the  pharynx  be  very  often  cleansed 
by  the  use  of  a  nebulizer,  chlorate  of  potash  in  powder  placed 
upon  the  tongue,  and  so  forth.  Dr.  Sexton  has  found  great 
relief  in  tonsillitis  from  the  use  of  the  warm  douche  upon  the 
pharynx,  by  means  of  Davidson's  syringe,  or  rubber  tubing- 
attached  to  a  water-faucet,  and  I  have  confirmed  this  experi- 
ence. 

Relapses  of  pain  should  be  combated  by  leeches,  warm  water, 
and  the  internal  administration  of  opium,  or  morphia,  chloral, 
and  bromide  of  sodium  combined ;  but  opium  has  very  little 
power  in  subduing  the  pain  from  acute  aural  suppuration,  if 
used  without  the  local  treatment.  The  administration  of  calo- 
mel or  other  mercurials,  the  application  of  blisters,  will  not  be 
required.  The  former  kind  of  treatment  is  useless,  while  the 
latter  aggravates  the  suffering  of  the  patient.  Blisters  are  more 
applicable  to  chronic  aural  disease,  but  in  the  absence  of  leeches 
they  are  useful. 

If  the  case  go  on  well,  a  physician  who  does  not  see  much 
of  this  form  of  disease,  will  be  astonished  at  the  rapidity  with 
which  the  suppuration  is  checked,  and  the  membrana  tympani 
restored.  The  impairment  of  hearing  will  be  the  last  symptom 
to  be  fully  relieved.  The  hearing  power  should  be  often  accu- 
rately tested  by  the  watch  and  tuning-fork  in  the  course  of  the 
disease,  in  order  that  if  possible  we  may  not  dismiss  the  patient 
until  the  cure  is  complete. 

The  astringent  that  I  usually  use  in  acute  suppuration  is  a 
solution  of  sulphate  of  zinc,  which  is  poured  into  the  ear  once  or 
twice  a  day,  after  syringing.  The  solution  should  be  previously 
warmed.  Should  the  suppuration  continue  unduly,  the  nitrate 
of  silver  may  be  applied  in  strong  solutions,  say  from  forty  to 
eighty  grains  to  the  ounce.  This  solution  is  brushed  over  the 
drum-head  and  in  the  edges  of  the  perforation.  In  some  cases 
it  may  be  necessary  to  drop  the  solution  into  the  ear,  afterward 
neutralizing  it  by  syringing  with  a  warm  solution  of  salt  and 


ACUTE  SUPPURATION — TREATMENT.  321 

water.  Indeed,  it  should  be  said  once  for  all,  that,  except  in  very 
rare  and  exceptional  cases,  cold  fluids  should  not  be  dropped 
into  the  ear. 

I  do  not  begin  the  use  of  astringents  in  the  treatment  of  acute 
suppuration,  until  I  have  assured  myself  by  careful  trial,  that 
the  cleansing  of  the  ear  is  not  of  itself  sufficient  to  cause  the 
purulent  discharge  to  cease.  In  many  cases  I  never  have  occa- 
sion to  use  an  astringent,  but  the  curative  influence  of  nature, 
impediments  to  her  action  being  removed,  proves  to  be  sufficient. 
Dr.  Ely,  who  was  for  years  associated  with  me,  both  in  private 
and  public  practice,  called  attention  to  this  subject,1  and  pub- 
lished some  cases  from  our  practice  which  I  here  insert  as  being 
of  great  illustrative  value  in  discussing  this  subject. 

Dr.  Ely  remarks  that  "  great  labor  has  been  required  to  lead 
physicians  and  laymen  to  consider  acute  suppuration  of  the 
middle  ear  as  of  any  importance,  and  it  is  natural  that  many 
practitioners  having  thus  been  laboriously  awakened  to  its  im- 
portance should  hold  exaggerated  ideas  as  to  the  remedies  re- 
quired for  its  cure." 


CASES  OF   ACUTE   SUPPURATION  OF  THE  MIDDLE  EAR  TREATED  WITH- 

OUT  ASTRINGENTS. 

Case  in  which  the  Use  of  an  Astringent  aggravated  the  Symptoms. 

Miss  H ,  aged  twenty,  consulted  me  November  30,  1877,  with  acute  sup- 
puration of  her  left  middle  ear  of  ten  days'  duration.  There  was  a  free  discharge 
of  pus,  and  no  pain  or  swelling.  I  ordered  syringing  of  the  ear,  and  the  instilla- 
tion of  a  two-grain  solution  of  sulphate  of  zinc  twice  daily.  Immediately  after 
using  the  zinc-drops  she  began  to  have  violent  pain  in  the  ear.  This  pain  con- 
tinued all  night,  and,  when  I  saw  her  the  next  day,  the  auditory  canal  was  so 
swollen  that  the  drum  could  not  be  seen ;  the  whole  of  that  side  of  the  face  was 
swollen  and  tender,  and  there  was  congestion  and  pain  in  the  eyeball.  There 
was  a  temperature  of  101°  and  some  vertigo.  Leeches,  hot  water,  morphine, 
and  rest  in  bed  were  prescribed.  The  pain,  swelling,  and  vertigo  did  not  dis- 
appear until  the  evening  of  December  4th.  I  always  attributed  this  attack  to 
the  effect  of  the  zinc,  although  I  have  no  further  proof  of  the  fact  than  the 
patient's  own  belief  of  it,  and  the  history  of  the  case. 

Cases  in  which  no  Astringents  were  Used. 

I. — Susie  M ,  aged  six,  came  on  November  llth  with  a  history  of  pain  in 

her  left  ear  from  6  o'clock  until  11  of  the  previous  evening.  The  drum-head 
was  found  congested  and  ruptured,  and  there  was  a  purulent  discharge.  Syr- 
inging of  the  ear  with  warm  water  twice  a  day  was  ordered.  On  the  14th 
there  was  no  discharge,  and  the  perforation  seemed  to  be  healing  ;  the  syringing 
was  discontinued.  On  the  16th  the  perforation  had  healed  and  the  hearing  was 

1  Archives  of  Otology,  vol.  viii.,  p.  178. 
21 


322  ACUTE  SUPPUKATION — TREATMENT. 

fully  restored.  II. — Miss  J.  H ,  aged  twenty-one,  came  on  March  llth,  hav- 
ing had  severe  pain  in  her  left  ear  since  3  A.M.  The  drum-head  was  found  rup- 
tured, and  there  was  purulent  discharge.  The  hearing  on  that  side  was  -&. 
Leeches  and  the  hot  douche  were  ordered,  and  they  seemed  to  arrest  the  pain 
at  once.  After  that,  the  ear  was  simply  syringed  occasionally  with  warm  water. 
On  the  13th  the  perforation  was  nearly  closed.  On  the  18th  it  was  completely 

healed,  and  the  hearing  was  1"-.     III. — Mrs.  M ,  aged  thirty-five,  came  on 

March  17th,  saying  that  she  had  had  a  cold  in  her  head  for  the  past  week  ;  that 
two  or  three  days  ago,  while  blowing  her  nose,  she  had  felt  a  "cracking"  in  her 
right  ear,  and  that  since  then  there  had  been  a  discharge  from  the  ear.  Before 
this  trouble  the  drum-head  on  that  side  was  cicatricial  from  a  suppuration  in 
childhood.  A  large  perforation  was  found  in  the  posterior  part  of  the  drum- 
head, with  a  muco-purulent  discharge.  The  hearing  was  -&.  Syringing  with 
warm  water,  two  or  three  times  a  day,  was  ordered.  On  March  19th  the  perfo- 
ration was  much  smaller;  the  discharge  was  still  abundant.  On  March  20th 
there  was  no  discharge.  The  next  day  her  cold  became  worse,  and  she  had 
some  fever.  The  following  three  days  she  had  throbbing  and  tinnitus  in  the 
right  ear  with  reappearance  of  the  discharge ;  also  had  some  vertigo.  Was 
taking  quinine  during  this  time.  On  the  25th  the  discharge  had  ceased,  and  a 

few  days  later  the  perforation  was  healed.     Hearing  -&.    IV. — Mr.W ,  aged 

forty,  came  on  February  24th  with  a  broken  drum-head  and  acute  suppuration, 
in  the  right  middle'  ear.  The  discharge  had  appeared  on  the  19th,  after  eight 
hours  of  pain  in  the  ear.  Syringing  with  warm  water  was  prescribed.  On 
February  27th,  the  discharge  was  found  to  be  less.  On  March  2d,  the  discharge 
had  ceased  and  the  perforation  was  veiy  small.  A  few  days  later,  the  drum-head 

was  found  to  be  healed  and  the  hearing  restored.     V. — Master  L ,  aged  five, 

came  June  17th  with  a  history  of  earaches,  both  sides,  for  the  previous  four 
weeks.  An  examination  showed  perforation  of  both  drum-heads  and  acute  sup- 
puration of  the  middle  ears.  No  treatment  was  employed  except  syringing  with 

warm  water.    The  patient  made  a  perfect  recovery.     VI. — Master  F ,  aged 

fourteen,  came  on  April  7th  with  acute  suppuration  of  the  left  middle  ear.  The 
use  of  the  warm  douche  was  prescribed.  On  April  17th  the  ear  was  doing  well, 
and  the  hearing  was  40-  A  few  days  after  this  the  patient  was  cured. 

In  this  case  and  the  preceding  one  the  exact  date  of  recovery 
was,  unfortunately,  not  recorded. 

VII. — Miss  M ,  aged  eighteen,  came  on  December  14th  with  acute  sup- 
puration of  the  right  middle  ear,  of  a  few  days'  duration.  She  had  already  had 
a  chronic  suppuration  of  that  ear,  following  measles,  which  had  been  checked, 
without  restoration  of  the  dram-head.  Warm  syringing  was  prescribed.  On 

January  14th  the  discharge  was  found  to  have  ceased.     VIII. — Master  V , 

aged  sixteen,  came  on  June  20th  with  an  acute  suppuration  of  the  left  middle 
ear.  The  discharge,  which  was  very  bloody,  had  been  noticed  by  the  patient  a 
day  or  two  previously,  after  a  night  of  very  severe  pain  in  the  ear.  There  had 
already  been  marked  deafness  on  both  sides,  from  chronic  catarrh,  for  many 
years.  The  only  treatment  prescribed  was  syringing  of  the  ear  with  warm 
water  two  or  three  times  a  day.  On  June  27th  the  drum-head  was  found  to  be 
healed.  There  had  been  no  discharge  for  several  days. 


ACUTE  SUPPURATION — TREATMENT.  323 

The  local  treatment  in  all  these  cases,  consisted  simply  in 
syringing  the  ear  with  warm  water  as  often  as  seemed  advis- 
able. Of  course,  the  throat  and  the  general  health  received 
attention  when  it  seemed  to  be  required. 

Criticisms  upon  Local  Antiphlogistic  Treatment  in  Aural 

Disease. 

Papers  have  been  written,  containing  elaborate  arguments 
against  the  use  of  leeches,  Wilde's  incision  down  to  the  perios- 
teum of  the  mastoid,  and  other  active  forms  of  treatment  of 
acute  aural  disease,  as  if  the  writers  who  advised  these  means 
in  cases  of  necessity,  always  found  them  necessary.  The  crit- 
icisms upon  active  treatment  in  acute  aural  disease  have  not 
always  been  discriminate,  for  they  have  sometimes  assumed 
that  the  modern  writers  advised  the  use  of  the  leeches  and  the 
knife  in  all  cases,  and  that  they  prescribed  a  routine  treatment 
without  using  their  judgment  as  to  each  individual  case.  I  am 
of  the  opinion  that  the  use  of  leeches,  paracentesis  of  the  drum- 
head, and  incision  of  the  mastoid,  have  all  the  importance  that 
has  been  ascribed  to  them  by  modern  otologists,  yet  I  have 
never  failed  to  counsel  circumspection  in  the  prescription  of 
active  means  of  treatment.  I  have  as  yet  found  no  means  of 
internal  treatment,  that  will  supersede  active  antiphlogistic 
means,  such  as  leeching  and  incisions  of  the  membrana  tym- 
pani  in  severe  cases  of  acute  disease  of  the  middle  ear.  There 
are  many  mild  cases,  however,  even  of  this  form  of  diseases, 
or  cases  of  an  asthenic  type.  In  these  the  surgeon  will  soon 
find  that  a  quiet  room,  the  warm  douche,  diaphoresis,  and  so 
forth,  will  often  be  sufficient  with  no  more  active  means.  As 
an  example  of  cases  of  acute  aural  disease  which  require 
constitutional  rather  than  local  treatment,  even  when  local 
symptoms  are  markedly  manifest,  the  following  case  heretofore 
published l  is  inserted.  It  is  a  striking  example  of  a  neurotic, 
rather  than  an  inflammatory  case,  a  variety  which  the  physician 
should  always  be  on  the  look-out  for,  among  hysterical  women 
and  overworked  men. 

Acute  Inflammation  of  the  Middle  Ear,  with  Inflammation  of  the  Muscles  of  the  Neck, 
and  Facial  Paralysis  of  the  Same  Side. 

May  5,  1879. — Dr.  S ,  aged  forty-five,  a  busy  surgeon  and  medical  jour- 
nalist, consulted  me  in  regard  to  uncomfortable  and  painful  sensations  in  his 
right  ear.  He  was  somewhat  anaemic,  jaded  from  overwork,  and  he  had  an 
anxious  appearance.  He  described  the  pain  as  extending  from  the  right  Eus- 

1  Archives  of  Otology,  vol.  viii.,  p.  255. 


324  NEUROSIS   OF   MIDDLE   EAR. 

tachian  tube  to  the  drum,  laying  great  stress  upon  the  pain  along  the  tube. 
The  drum-head  was  red,  the  auditory,  canal  normal.  There  was  nothing  marked 
about  the  pharynx.  The  hearing  distance  was  not  noted.  Leeches  were  or- 
dered to  be  applied  to  the  tragus.  I  afterward  learned  that  he  had  slight  nasal 
catarrh  and  headache  with  pain  in  right  lower  jaw,  on  May  4th.  The  next  day 
I  received  a  note  from  the  patient  stating  that  he  did  not  feel  able,  on  account 
of  the  pain,  to  come  to  my  office,  which  was  a  very  short  distance  from  his.  I 
found  him  in  bed  and  apparently  suffering  very  much.  He  complained  of  a 
pain  like  that  from  neuralgia,  extending  over  the  right  side  of  the  scalp,  face, 
neck,  the  right  auditory  canal,  and  the  Eustachian  tube.  Leeches  and  the  hot 
douche  were  prescribed.  The  patient  then  told  me  that  he  had  suffered  very 
severely  a  few  weeks  before  from  facial  neuralgia ;  that  he  then  had  no  aural 
trouble ;  that  he  had  had  very  lately  an  inflammation  of  the  muscles  of  the  op- 
posite side  of  the  neck.  The  membrana  tympani  was  vascular,  but  not  bulging. 
Knowing  that  this  patient  had  been  very  much  overworked,  with  an  insufficient 
quantity  of  fresh  air,  and  seeing  that  he  was  pale  and  hyper-sensitive,  I  con- 
sidered the  pain  as  out  of  proportion  to  the  objective  symptoms  of  inflamma- 
tion, and  I  therefore  made  a  diagnosis  of  non-suppurative  inflammation  of  the 
middle  ear,  with  neuralgia  of  the  fifth  nerve.  In  other  words,  I  believed  that 
the  otalgic  symptoms  predominated  over  those  of  true  inflammation.  Warm 
applications  behind  and  over  the  ear  were  advised,  as  well  as  the  use  of  the 
hot  douche.  The  hot  douche  was  not  well  borne,  nor  was  there  much  relief, 
except  at  short  intervals,  from  these  measures.  It  should  also  be  said  that  I 
laid  great  stress  upon  maintaining  the  nutrition,  and  a  generous  diet  was  in- 
sisted upon.  On  the  fourth  or  fifth  day  the  auditory  canal  was  somewhat 
swelled,  but  not  tender.  I  incised  the  drum-head,  but  no  pus  or  mucus  was 
evacuated.  The  hot  douche  was  now  freely  used  and  afforded  relief.  A  very 
moderate  suppuration  occurred  in  the  tympanic  cavity.  Morphia  was  adminis- 
tered, pro  re  nata.  The  patient  sat  sometimes  out  of  bed,  but  did  only  tolerably 
well,  complaining  at  intervals  of  veiy  severe  neuralgic  pain  which  was  relieved 
by  morphia.  He  took  nourishment  badly,  except  in  the  intervals  of  freedom 
from  pain.  He  was  very  much  depressed  in  spirits.  There  was  no  tenderness 
or  any  other  inflammatory  symptoms  on  the  mastoid  or  in  the  pre-auricular 
region.  On  May  15th — ten  days  after  I  first  saw  the  patient — I  went  out  of  town 
to  fill  a  professional  engagement,  and  my  associate,  Dr.  E.  T.  Ely,  took  charge 
of  the  case  until  May  25th,  and  his  notes  are  as  follows  : 

"Dr.  S seems  to  be  a  case  of  acute  suppuration  of  the  middle  ear,  with 

considerable  swelling  of  the  auditory  canal ;  slight  discharge  ;  no  pain. 

"May  16th. — More  pain  and  swelling;  no  discharge. 

"May  17th. — Severe  pain  in  whole  right  side  of  face  and  head  and  in  the  ear, 
not  controlled  by  douche ;  no  discharge ;  funnel-shaped  swelling  of  the  canal, 
not  very  tender.  Consultation  with  Dr.  A.  H.  Buck.  It  was  decided  to  incise 
the  canal  and  reopen  the  drum-head.  This  was  done  under  ether.  The  open- 
ing in  the  drum-head  was  very  free,  and  the  canal  was  incised  from  the  bottom 
to  the  entrance.  Three  leeches  were  then  applied  to  the  tragus  and  one  to  the 
mastoid.  Hot  douche  was  continued.  No  pus  followed  these  incisions. 

"May  18th. — Pain  most  of  last  night.  A  little  easier  this  morning.  Dis- 
charge of  pus  beginning. 

"May  19th. — Comfortable  until  evening,  then  great  pain  in  ear  and  head; 
temperature,  101^° ;  three  leeches  to  mastoid ;  douche ;  morphia. 


NEUROSIS   OF  MIDDLE   EAR.  325 

"May  20th. — Not  much  pain ;  weak  and  depressed.  A.M.:  Temperature,  98£°  ; 
pulse,  88  ;  P.M.  :  temperature,  100^° ;  pulse,  88.  Slept  most  of  the  day. 

"May22d. — No  fever  yesterday  or  to-day;  one  attack  of  severe  pain  last 
night ;  canal  red  and  swollen ;  free  discharge  since  incision ;  four  leeches  ap- 
plied, and  hot  douchfe,  for  twenty  minutes  every  two  hours. 

"  May  24th. — Pain  part  of  every  day,  no  fever;  severe  pain  last  evening  qui- 
eted by  morphia  ;  slight  mastoid  tenderness  and  oadema  last  evening  and  this 
morning  ;  less  swelling  in  canal.  Dr.  Buck  was  again  called  in  consultation ;  he 
advised  opening  the  mastoid  by  trephining.  Dr.  C.  R.  Agnew  was  called  in  the 
afternoon.  He  considered  the  case  a  typical  one  of  mastoid  disease  of  prolifer- 
ous nature,  but  that  no  suppuration  was  going  on  there.  He  thought  the  dis- 
ease was  chiefly  in  the  mastoid  from  the  outset,  and  that  there  was  meningeal 
congestion.  By  the  ophthalmoscope  the  veins  in  the  right  fundus  seemed  a 
little  fuller  to  Dr.  A.  and  to  Dr.  Ely  than  in  left. 

May  25th. — Very  slight  oadema  and  some  tenderness  over  mastoid,  and  al- 
though only  one  dose  of  the  iodide  of  potassium  prescribed  the  day  before  was 
taken,  iodism  was  produced.  Patient  was  awake  all  night  from  sneezing,  and 
had  some  pain  in  the  other  ear.  He  is  nervous  and  hysterical,  buries  his  head 
in  the  bedclothes,  and  refuses  to  be  comforted.  He  expresses  the  belief  that  he 
will  not  recover.  On  this  date  I  met  a  gentleman  with  very  large  aural  experience, 
and  we  went  over  the  case  very  carefully.  The  patient  seemed  to  be  suffering  very 
much,  and  he  located  the  seat  of  his  pain  by  spreading  out  his  hands  like  a  fan 
over  the  right  side  of  the  head.  The  tenderness  about  the  ear  was  not  very  great, 
and  was  found  in  the  neck  and  occiput  as  well.  The  ear  was  discharging  freely 
with  healthy  pus.  The  mastoid  was  so  slightly  cedematous  that  I  thought  its 
condition  might  be  due  to  the  leeches  and  other  applications.  It  did  not  seem 
to  me  to  be  a  case  of  mastoid  periostitis,  nor  did  I  think  there  was  any  meningitis 
or  cerebral  disease.  Although  I  did  not  feel  so  sure  of  the  former  point  as  of  the 
latter,  I  still  thought  the  pain  was  neuralgic  rather  than  inflammatory.  Inasmuch, 
however,  as  Dr.  Agnew  had  on  the  day  before  given  the  opinion  that  the  mastoid 
was  markedly  involved,  and  that  there  was  a  meningeal  hyperaernia,  and  as  the 
gentleman  now  in  consultation  was  much  more  decided  in  the  opinion  that  the 
mastoid  was  the  point  of  the  origin  of  the  pain,  and  moreover,  since  my  own 
judgment  was  a  little  doubtful  and  wavering,  I  advised  that  a  Wilde's  incision 
be  made  at  once.  If  this  incision  failed  to  detect  disease  of  the  bone,  I  resolved 
to  take  no  further  operative  steps  at  this  time,  although  the  gentleman  in  con- 
sultation afterward  stated  to  me,  that  he  considered  this  but  a  step  in  the  right 
direction,  he  believing  that  the  bone  should  be  opened,  and  that  even  if  no  pus 
were  found,  the  bone-fistula  would  do  no  harm.  The  incision  was  accordingly 
made  ;  no  disease  of  the  bone  was  found.  The  wound  was  dressed  to  the  bot- 
tom with  lint,  and  a  poultice  was  applied. 

May  28th. — The  pains  in  the  head  and  neck  are  not  at  all  relieved  except 
when  morphia  is  used  in  full  doses.  The  tissiies  of  the  mastoid,  pre-auricular 
region,  and  neck  were  red,  swelled,  and  tender  at  various  points.  These  symp- 
toms have  increased  since  the  incision.  The  depression  of  spirits  continues,  but 
at  times  the  patient  can  be  made  quite  cheerful  by  light  conversation,  and  after 
a  dose  of  morphia.  He  is  taking  a  moderate  amount  of  stimulants,  and  milk 
quite  freely.  Dr.  William  A.  Hammond  was  called  in  consultation ;  his  opinion 
was  that  there  was  no  disease  in  the  cranium*,  and  that  the  pain  was  due  to  neu- 
ralgia largely  modified  by  malaria.  He  advised  that  60  grs.  of  quinine  be  given. 


326  NEUEOSIS   OF   MIDDLE  EAE. 

in  twenty-four  hours,  for  two  days,  and  that  this  treatment  be  followed  up  by 
small  doses  of  arsenic.  This  treatment  was  followed  by  an  apparent  alteration 
of  the  pain,  and  not  so  much  morphia  was  needed. 

On  June  3d  the  muscles  of  the  neck  were  so  much  swelled  that  we  pronounced 
them  in  a  state  of  inflammation,  and  leeches  were  applied.  The  arsenic  and 
generous  diet,  as  far  as  patient  would  take  it,  with  moderate  doses  of  alcohol, 
were  continued.  The  neck  was  especially  tender  where  nerves  made  their  exit. 
There  was  no  especial  tenderness  on  the  rnastoid;  the  patient  could  scarcely 
move  his  head  from  side  to  side. 

June  7th. — The  conjunctiva  and  outside  of  lids  of  right  eye  are  reddened; 
the  ability  to  close  the  right  eye  is  impaired. 

June  8th. — Conjunctiva  and  lids  less  red  than  yesterday.  Slight  enlargement 
of  gland  at  the  angle  of  the  jaw  on  right  side.  Severe  pain  in  the  jaw  and  mas- 
toid region.  Morphine  was  freely  administered  hypodermically  for  its  relief. 
A  poultice  was  kept  on  the  side  of  the  face  and  the  head.  Temperature,  101|° ; 
pulse,  100. 

June  9th. — Swelling  at  the  angle  of  the  jaw  increased ;  pain  severe,  and  facial 
paralysis  on  the  right  side  well  marked.  The  right  lid  does  not  completely  close 
in  winking.  The  right  side  of  the  face  appears  rounder  and  fuller  than  the  left, 
and  the  mouth  is  slightly  drawn  toward  the  left.  The  tongue  protrudes  in  a 
direct  line,  and  there  is  no  deviation  in  the  uvula.  There  is  apparently  no  dis- 
turbance of  the  sense  of  smell.  Temperature,  99|° ;  pulse,  94.  Two  leeches 
were  applied  behind  the  ear.  P.M.:  Severe  pain;  1H.  x.  of  Magendie's  solution 
every  three  hours  (hypodermically). 

June  10th. — A.M.:  Temperature,  98i° ;  pulse,  100.  Slept  well;  took  about 
one  quart  of  milk  during  the  night.  Facial  paralysis  increased.  Ophthalmo- 
scopic  examination  by  Dr.  Eoosa.  The  appearance  of  the  fundus  is  the  same  in 
both  eyes,  and  nothing  abnormal  is  seen  in  either.  The  ear  discharges  freely. 
P.M.:  Longer  intervals  of  freedom  from  pain.  No  morphine  since  the  8th  at 
9  P.M. 

June  llth. — A.M.  :  Temperature,  99|°.  Swelling  at  the  angle  of  the  jaw  dimin- 
ished. No  pain  since  June  10th  at  9  P.M.  P.M.  :  Pain  recurs ;  not  so  severe. 
Chloral  and  bromide  of  sodium  are  given  for  its  relief. 

June  12th. — A.M.:  Patient  slept  badly.  Pain  returned  in  the  old  regions,  the 
jaw,  behind  the  ear,  and  over  the  right  side  of  the  head.  Temperature,  98|°  ; 
pulse,  94.  Patient  very  much  depressed  in  spirits.  Morphia  again  administered. 
At  5  *P.M.  a  consultation  was  held,  at  which  were  present  Dr.  Alfred  L.  Loomis, 
Dr.  Henry  B.  Sands,  Dr.  Charles  E.  Briddon,  Dr.  W.  M.  Carpenter,  and  the 
attending  physician,  Dr.  Eoosa.  After  Dr.  Eoosa's  statement  that  the  pus  was 
freely  discharging  from  the  auditory  canal,  and  that,  in  his  opinion,  there  was 
no  retained  pus  in  the  bone,  without  claiming  to  decide  the  strictly  aural  points 
of  the  case  positively,  the  conclusion  was  reached  by  the  consulting  surgeons 
and  physicians  that  the  patient  had  no  symptoms  of  intra-cranial  trouble ;  that 
there  was  no  indication  for  operative  interference  with  reference  to  the  mastoid 
process,  or  suppuration  in  any  part  of  the  neck  ;  that  supporting  treatment  was 
demanded.  On  the  suggestion  of  Dr.  Loomis  the  stimulant  he  was  receiving 
was  increased  to  1^  oz.  of  whiskey  every  three  hours,  and  pushed  to  2  ozs.  as  soon 
as  it  became  evident  that  it  did  not  disagree  with  his  stomach. 

June  13th. — Patient  feels  very  comfortable ;  has  slept  well ;  is  taking  2  ozs.  of 
whiskey  in  a  tumbler  of  milk  every  three  hours,  and  has  not  experienced  the 


NEUROSIS   OF   MIDDLE   EAE.  327 

slightest  intoxicating  effect.  Takes  nourishment  aside  from  the  milk.  Temper- 
ature, 99°  in  the  morning,  98|°  6  P.M.  ;  pulse,  between  96  and  100.  Patient  also 
takes  citrate  of  iron  and  quinine.  A  8  P.M.  patient  again  complains  of  severe 
pain.  Morphia  administered  at  9.30  P.M. 

At  3  A.M.  on  June  14th  he  was  seen  by  Dr.  Ely  on  account  of  great  pain. 
Morphia  was  given  at  that  time  and  one  hour  later.  At  8  o'clock  the  pain  was 
still  unrelieved,  and  the  swelling  about  the  angle  of  the  jaw  and  the  mastoid 
process  was  very  much  increased.  Morphia  was  freely  administered  p.  r.  n.,  and 
a  consultation  was  held  at  1.30  P.M.,  at  which  three  aural  surgeons  and  one  gen- 
eral surgeon  were  present.  The  following  opinions  were  given :  Dr.  ,  an 

otologist,  saw  no  indication  for  operative  procedure,  while  he  believed  there  was 
mastoid  disease.  Dr. ,  also  an  otologist,  believed  that  the  patient  was  suffer- 
ing from  mastoid  disease,  and  that  trephining  should  be  performed  at  once. 

Dr. ,  aural  surgeon,  thought  there  was  no  serious  internal  trouble,  that  it 

was  external,  and  that  the  patient  was  probably  suffering  from  some  kind  of 
poisoning — malarial?  sewer  gas?  that  no  operation  was  advisable.  The  general 
surgeon  thought  that  pus  would  be  found  somewhere  about  the  stylo-mastoid 
process,  and  he  thought  that  nature  would  relieve  the  patient  by  suppuration. 
He  laid  great  stress  on  the  continued  application  of  poultices,  and  he  was  not  in 
favor  of  operative  interference  to-day.  Dr.  Roosa  adhered  to  his  original  opinion, 
that  the  patient  had  a  moderate  inflammation  of  the  middle  ear,  with  great  neu- 
ralgic pain,  and  that  the  swelling  of  the  neck  and  facial  paralysis  may  have  been 
caused  by  the  operative  procedures  already  undertaken,  and  that  trephining  was 
not  justifiable,  but  that  it  would  be  injurious.  It  was  decided  to  continue  the 
alcohol  and  to  make  the  application  of  poultices  very  thoroughly  over  the  neck 
and  mastoid. 

An  examination  of  the  urine  on  June  15th  gave  the  following  result :  Dark 
straw-color,  acid,  sp.  gr.  1024,  albumen  in  moderate  quantity,  casts  2,  slightly 
granular,  uric  acid  a  little,  pus  a  little,  mucus  a  fair  amount,  oxalate  of  lime 
a  little. 

June  loth. — The  ear  is  suppurating  moderately.  The  drum-head  is  gran- 
ular, canal  moderately  swelled,  ear  easily  inflated  by  Politzer's  method.  The 
swelling  in  the  course  of  the  sterno-cleido-mastoid  muscle,  and  about  the  neck, 
seems  to  be  increased,  but  the  tenderness  is.  not  so  marked.  The  symptoms 
point  to  abscess  forming  in  the  connective  tissue,  and  in  the  muscles  of  the  neck, 
and  over  the  mastoid  process.  Dr.  Eoosa  does  not  think  there  is  retained  pus 
anywhere  in  the  head,  or  inside  of  the  temporal  bone.  There  is  a  particularly 
tender  point,  l£  in.  in  a  direction  directly  backward  and  a  little  downward  from 
the  lobe  of  the  ear.  There  is  scarcely  any  oedema  about  the  Wilde's  incision. 
Temperature,  99°;  pulse,  100.  3  P.M.:  The  swelling  has  begun  to  subside.  Dr. 

,  a  general  surgeon  who  had  seen  the  patient  on  the  13th,  saw  the  patient 

this  afternoon,  and  fhinks  it  possible  there  is  pus  in  the  petrous  portion  of  the 
temporal  bone,  and  that  the  swelling  may  be  due  to  a  temporary  plugging  up  of 
the  communication  with  the  tympanic  cavity. 

Dr.  Eoosa  thinks  there  may  be  pus  in  the  cellular  tissue,  but  does  not  think 
that  it  is  necessarily  connected  with  the  tympanic  cavity.  The  treatment  was 
continued. 

June  16th. — Pulse,  98 ;  temperature,  99°.  Patient  slept  well.  Dr.  Eoosa 
opened  the  track  of  the  Wilde's  incision  with  a  probe.  The  swelling  and  oedema 
in  the  mastoid  process  and  about  the  angle  of  the  jaw  remained  the  same. 


328  NEUROSIS   OF   MIDDLE  EAR. 

Another  consultation  was  held  during  the  day,  at  which  there  were  present 
two  general  surgeons,  two  otologists,  and  Drs.  Boosa  and  Carpenter.  One  of 
the  surgeons  expressed  the  opinion  that  the  patient's  general  condition  had  im- 
proved since  he  last  saw  him,  but  he  declined  to  express  any  opinion  in  regard  to 
the  necessity  for  operative  interference  with  the  ear.  He  believed  it  possible 
that  the  operations  already  performed  might  have  aggravated  the  symptoms. 
The  other  general  surgeon  inclined  toward  trephining  the  mastoid.  This  should 
certainly  be  done  in  his  opinion  if  there  is  a  probability  that  there  is  not  a  free 
opening  from  the  mastoid  cells  into  the  tympanic  cavity,  and  this  was  a  point  to 
be  decided  by  the  aural  surgeons.  One  of  the  otologists  thought  the  patient 
better,  and  that  no  operation  should  be  done.  The  other  aural  expert  believed 
that  the  bone  should  be  opened.  Dr.  Boosa  stated  that  his  opinion  was  un- 
changed, but  that  he  had  so  much  respect  for  the  opinion  of  the  gentleman  who 
was  so  decided  with  regard  to  the  necessity  for  an  operation,  as  well  as  fov  that 
of  the  one  who  was  inclined  toward  it,  that  he  wished  for  further  advice  before 
he  declined  to  open  the  mastoid.  By  agreement  Dr.  Bobert  F.  "Weir,  who  was 
for  some  years  aural  surgeon  to  the  Eye  and  Ear  Infirmary,  and  who  is  now  sur- 
geon to  two  general  hospitals,  was  invited  to  see  the  patient  independently  and 
alone,  at  9  o'clock  this  evening,  without  knowing  any  of  the  opinions  that  had 
been  expressed,  until  his  own  was  formed.  Dr.  Weir  gave  the  following  opinion : 
that  the  disease  is  probably  an  inflammation  extending  down  the  external  audi- 
tory canal,  in  the  angle  close  to  the  point  where  the  facial  nerve  passes,  and  that 
it  may  perhaps  involve  the  mastoid  process;  he  is  inclined  to  think  it  does  not ; 
there  is  no  indication  for  surgical  interference  for  the  present.  The  general  plan 
of  treatment  was  therefore  continued. 

June  17th. — An  examination  of  the  urine  made  this  day  shows  specific  gravity 
1020,  and  a  well-marked  trace  of  albumen.  No  casts.  The  general  condition  of 
the  patient  is  improving,  and  the  swelling  about  the  neck  is  subsiding. 

June  19th. — Patient  is  still  doing  well.     Treatment  has  been  continued. 

The  patient  made  a  good  recovery,  with  fair  hearing  distance,  4%  at  the  last 
note,  and  has  been  ever  since  actively  employed  in  his  profession. 

I  regret  very  much  that  the  early  notes  of  this  case  are  not 
more  full ;  yet  I  think  they  are  sufficiently  so  to  give  my  readers 
a  fair  idea  of  the  first  symptoms.  It  is  probable,  however,  that 
the  mere  recital  has  not  conveyed  to  the  minds  of  those  who 
have  followed  it  a  full  sense  of  its  doubtful  features.  They  were 
such  that,  taken  in  connection  with  the  patient's  high  profes- 
sional position,  they  gave  me  great  anxiety  lest  I  should  omit  to 
do  my  full  surgical  duty  to  the  case.  -The  more  recent  of  the 
notes  were  taken  stenographically  by  Dr.  W.  M.  Carpenter,  to 
whom  the  patient  was  indebted  for  intelligent  and  assiduous 
care. 

The  point  to  be  settled  during  the  course  of  the  disease  was 
this  :  Is  there  a  hidden  suppurative  process  going,  on  in  any 
part  of  the  temporal  bone  which  causes  the  pain,  oedema,  ten- 
derness, cellulitis,  myositis,  and  paralysis  of  the  facial  ?  My 
answer  to  the  question  was,  No.  The  severe  paroxysmal  pain 


NEUROSIS    OF   MIDDLE   EAE.  329 

did  not  arouse  the  suspicion  in  my  mind  that  there  was  mastoid 
disease,  because  there  was  absolutely  no  well-defined  tender- 
ness, redness,  or  oedema  until  leeches  and  poultices  had  been 
freely  applied,  and  not  until  two  paracenteses  of  the  drum-head 
and  very  free  incisions  of  the  auditory  canal  had  been  made. 

On  May  25th,  when  I  saw  the  patient  after  an  absence  of  ten 
days,  there  was  certainly  a  moderate  amount  of  oedema,  and 
this  led  me,  although  I  suspected  it  had  been  caused  by  the 
leeching,  to  advocate  a  Wilde's  incision,  especially  as  I  then 
thought  it  a  harmless  procedure,  and  two  otologists,  who  had 
seen  the  patient  with  Dr.  Ely,  thought  the  disease  markedly  in- 
volved the  mastoid,  although  only  one  of  them  advocated  any 
operative  procedure.  I  now  think  that  this  incision,  was  a  mis- 
take, and  that  to  it  we  owe  the  increase  of  the  inflammatory 
symptoms  in  the  neck  and  the  facial  paralysis.  Indeed  I  now 
believe,  on  a  calm  looking  over  of  the  case,  that  every  operative 
interference,  from  my  first  paracentesis  down  to  the  Wilde's  in- 
cision, was  unnecessary,  and  that  the  traumatism  needlessly 
aggravated  the  painful  case.  The  key-note  was  struck  in  the 
proper  management  of  the  case,  in  my  opinion,  when  the  sup- 
porting, anodyne  and  anti-malarial  treatment,  by  means  of  milk, 
alcohol,  morphia,  and  quinine  was  vigorously  entered  upon. 

I  believe,  furthermore,  that  the  disease  would  have  been 
more  easily  subdued  if  I  had  gotten  the  patient  out  of  his  house 
and  by  the  seaside,  before  the  graver  symptoms  set  in.  This  I 
urged  upon  the  patient  and  his  friends,  but  without  avail.  It 
was  simply  a  case  of  sub-acute,  non-suppurative  inflammation 
of  the  Eustachian  tube  and  tympanic  cavity,  occurring  in  an 
anaemic,  and,  consequently,  neuralgic  and  hysterical  subject. 
That  he  was  anaemic  was  not  only  noted  by  me  at  my  first  inter- 
view, but  when  Dr.  Loomis  was  called  in  consultation,  he  stated 
that  he  had  noticed  the  doctor's  anaemic  condition  for  a  year. 

Neuralgic  he  certainly  was,  for  he  had  barely  gotten  through 
with  a  severe  attack  of  facial  neuralgia  when  the  trouble  oc- 
curred in  the  ear.  The  character  of  the  pain  during  the  whole 
course  of  the  disease  was  not  that  arising  from  deep-seated 
trouble  in  the  middle  ear,  but  rather  of  a  disease  like  neuralgia, 
in  which  there  is  an  intensity  at  different  times,  and  which  has 
intervals  of  complete  cessation.  It  was  sometimes  easy  to  divert 
the  patient  by  light  conversation  or  an  anecdote,  for  quite  a 
long  time,  and  on  some  few  occasions  the  use  of  water  in  the 
hypodermic  syringe  was  followed  by  as  much  effect  as  the  em- 
ployment of  morphia.  Now,  the  character  of  a  pain  caused  by 
severe  inflammatory  action  in  the  tympanic  cavity  or  mastoid 
process  is  such  that  no  physician  who  has  seen  much  of  it  would 


330  NEUROSIS   OF   MIDDLE   EAR. 

attempt  to  alleviate  it  by  any  diversion  of  the  patient's  spirits 
or  by  a  placebo.  Only  positive  means,  such  as  local  blood-let- 
ting or  division  of  the  periosteum,  will  subdue  this.  I  have  long 
since  recorded  my  experience  :  that  morphia  alone  will  not  mask 
the  severe  pain  of  an  acute  inflammation  of  the  middle  ear.  As 
Von  Troltsch  aptly  says,  an  inflammation  of  the  tympanic  cav- 
ity is  essentially  a  periostitis,  and  every  surgeon  knows  of  what 
little  avail  are  drugs  against  the  pain  of  this  disease,  except 
when  it  occurs  as  a  result  of  the  deposition  of  syphilitic  poison. 
It  should  have  been  said  before  that  this  patient  had  no  syphi- 
litic taint  whatever. 

I  considered  the  patient  to  be  nervous  and  hysterical,  because 
he  bore  his  pain  very  badly,  and  because  he  suffered  from  very 
great  depression  of  spirits.  It  is  not  usual,  in  my  experience, 
for  a  patient  suffering  from  acute  inflammation  of  the  middle 
ear,  to  dwell  very  much  on  his  prospects  of  recovery,  or  to  be 
greatly  depressed  about  his  future.  He  is  generally  taken  up  so 
much  with  the  severity  of  his  pain  as  to  have  room  for  nothing 
else.  Then  there  was  something  in  the  history  of  the  house  in 
which  the  patient  lived,  which  I  failed  to  impress  upon  some  of 
the  gentlemen  who  saw  him  with  me,  which  led  me  to  believe, 
as  was  once  independently  suggested  by  Dr.  Noyes,  who  saw 
him  two  or  three  times,  that  there  was  an  element  of  blood- 
poisoning  in  the  case,  perhaps  from  sewer-gas.  Two  members 
of  the  family  had  suffered  from  acute  aural  disease  a  few 
months  before,  and  an  examination  made  by  competent  au- 
thority late  in  the  course  of  the  case,  showed  that  there  was  an 
escape  of  sewer-gas  in  the  cellar.  I  do  not  know  that  any  spe- 
cial significance  is  to  be  attached  to  the  presence  of  albumen  in 
the  urine,  but  so  far  as  it  goes,  it  indicates  a  somewhat  deteri- 
orated general  condition.  In  analyzing  the  case,  I  come  over 
and  over  again  to  the  conviction  that  the  operations  did  harm. 
That  traumatism  such  as  the  patient  experienced  in  the  para- 
centesis,  and  in  the  very  free  subsequent  division  of  the  mem- 
brana  tympani,  and  the  free  incisions  in  the  auditory  canal,  and 
the  cut  down  to  the  mastoid  bone,  might  induce  adenitis,  myo- 
sitis,  cellulitis,  and  that  facial  paralysis  might  result  from  press- 
ure upon  the  nerve  as  it  makes  its  way  out  of  the  stylo-mastoid 
foramen,  I  think  does  riot  admit  of  a  doubt.  Certainly  there 
never  was  any  evidence  that  the  facial  suffered  any  lesion  until 
after  it  had  left  the  cranium  and  tympanic  cavity.  Besides,  the 
swelling  and  paralysis  occurred  at  a  point  of  time  which  makes 
it  possible  to  believe  that  traumatism  may  have  caused  them. 

1  Transactions  of  the  American  Otological  Society,  p.  89.    1875. 


ACUTE   SUPPURATION — RESULTS.  331 

But,  the  crucial  test  of  the  correct  diagnosis  was  in  the  results 
of  the  case.  There  was  no  escape  of  retained  pus  either  from 
the  mastoid  or  from  the  neck.  It  certainly  was  not  pus  which 
caused  the  serious  symptoms.  When  they  were  at  their  height 
the  discharge  from  the  ear  went  on,  but  gradually  diminished. 
And  when  the  patient  was  fairly  convalescent,  and  up  and 
about,  the  old  swelling  and  redness  of  the  neck  reappeared  for 
several  hours.  Besides,  it  should  be  noted  that  no  chill  occurred 
during  the  progress  of  the  case.  This  fact,  together  with  the 
clearness  of  the  patient's  intellect,  gave  me  great  encourage- 
ment, when  I  was  struggling  against  the  opinion  of  a  valued 
colleague,  who  thought  the  patient  was  dying  for  want  of  an 

operation.  Dr.  S was  relieved  after  large  doses  of  quinine 

at  a  time  when  the  pain  was  intense,  and  when  these  seemed  to 
fail,  he  was  permanently  cured  after  the  full  doses  of  alcohol 
advised  by  Dr.  Loomis. 

From  the  nature  of  things,  the  general  practitioner  will  see 
a  great  deal  of  acute  disease  of  the  middle  ear — if  he  be  on  the 
lookout  for  it — since  it  occurs  so  often  in  the  course  of  the  ex- 
anthemata and  in  connection  with  diseases  of  the  respiratory 
organs.  It  will  be  seen  that  there  is  nothing  in  the  treatment 
of  this  affection  that  will  prevent  the  usual  care  of  the  general 
disease.  It  is  a  great  and  often  fatal  error  to  wait  the  subsid- 
ence of  the  genera]  symptoms  before  the  aural  ones  are  allevi- 
ated. They  are  quite  as  important  as  the  most  urgent  consti- 
tutional disturbances.  Indeed,  they  are  often  the  unsuspected 
cause  of  most  of  the  latter. 

It  only  remains  to  be  said  that  the  results  of  treatment  of 
this  disease  are  very  satisfactory.  I  think  more  than  seventy- 
five  per  cent,  of  these  cases  are  cured,  that  is,  the  membrana 
tympani  is  restored  and  the  hearing  power  becomes  normal.  As 
has  been  said  in  another  place,  the  old  writers  on  diseases  of  the 
ear  were  not  in  the  habit  of  applying  accurate  tests  as  to  the 
restoration  of  hearing ;  so  that  their  standard  of  cure  is  not  so 
high  as  that  which  obtains  among  writers  of  the  present  day. 
Many  of  my  cases  of  aural  disease,  that  have  been  reported  as 
improved  or  much  improved,  would  have  been  classed  under  the 
head  of  cured,  by  the  less  exact  standard  of  ancient  writers. 
Where  one  ear  only  is  affected,  we  are  apt  to  be  led  into  error 
as  to  the  amount  of  deafness,  unless  we  are  careful  to  exclude 
the  sound  ear  as  thoroughly  as  may  be  in  our  examination. 

The  consequences  of  a  neglected  or  improperly  treated  aural 
catarrh  are,  that  it  runs  into  a  case  of  acute  suppuration ;  but 
those  of  a  neglected  or  maltreated  acute  suppuration  are  still 
more  grave,  involving  as  they  do  all  the  perils  of  long-continued 


332  ACUTE   SUPPURATION — RESULTS. 

suppuration  in  the  ear.  And  yet,  to  this  day,  there  are  medical 
men  of  very  great  general  intelligence,  who  think  lightly  of  such 
a  disease,  and  gravely  advise  patients  not  to  "meddle"  with  it. 
The  author  has  been  informed  by  a  distinguished  practitioner  in 
this  city,  that  a  young  man  was  once  sent  to  him  for  advice  by 
an  eminent  physician,  after  he  had  passed  through  a  severe  con- 
stitutional disease  in  which  suppuration  in  the  middle  ears  had 
occurred,  for  whose  ears  not  one  particle  of  rational  advice  had 
been  given,  although  both  membranse  tympani  had  been  de- 
stroyed, the  ossicula  were  gone,  and  the  mucous  membrane  of  the 
tympanic  cavity  was  granular.  Such  neglect  needs  no  com- 
mentary. 

Occasionally  I  receive  a  note  from  a  general  practitioner, 
which  conveys  the  impression  to  me,  that  it  is  supposed  by  some, 
that  peculiar  means  of  treatment  are  at  the  service  of  specialists 
which  are  not  in  the  hands  of  the  average  physician,  and  which 
can  only  be  used  when  a  disease  has  become  well  advanced.  To 
those  who  hold  such  views,  I  would  say,  the  time  to  treat  aural 
disease  is  in  the  beginning  of  the  attack.  Aurists  or  surgeons 
have  no  means  to  combat  inflammation  other  than  those  at 
the  hands  of  every  practitioner.  To  wait  for  so-called  special 
treatment  is  to  lose  important  time.  Besides  this,  there  is  no 
special,  mysterious  treatment  that  can  be  of  avail  at  any  time, 
no  matter  in  what  hands.  It  is  true  that  we  must  wait  for  a  cat- 
aract to  ripen,  before  it  can  be  removed,  and  then  only  an  expert 
is  competent  to  operate  upon  it.  But  no  such  condition  of  things 
exists  in  the  progress  of  aural  disease.  Delay  in  its  manage- 
ment will  be  as  fatal  to  a  cure,  as  is  delay  in  the  treatment  of 
glaucoma. 

The  course  of  acute  suppuration  occurring  in  the  midst  of 
a  severe  attack  of  scarlatina,  is  apt  to  be  violent.  The  symp- 
toms follow  one  another  with  the  rapidity  of  those  of  purulent 
ophthalmia.  He  who  wishes  to  preserve  the  integrity  of  the 
organ,  must  be  prompt  and  energetic  in  his  treatment,  or  the 
drum-head  and  the  ossicula  auditus  will  be  swept  away,  and  a 
profuse  and  fetid  discharge  of  pus  be  set  up  within  forty-eight 
or  fifty-six  hours. 

It  should  also  be  said  as  supplementary  to  this  subject,  that 
attacks  of  acute  aural  catarrh,  or  of  acute  suppuration  of  the 
middle  ear,  are  more  dangerous  in  persons  who  are  affected  with 
a  chronic  catarrh  of  the  middle  ear.  This  is  explained  by  the 
fact,  that  the  drum  membrane  is  so  much  thickened  in  such  cases 
that  the  exit  of  the  pus  or  mucus  by  its  spontaneous  perforation 
is  much  more  difficult.  A  paracentesis  will  be  much  more  likely 
to  be  required  for  them,  than  in  those  occurring  in  persons  with 


ACUTE   SUPPURATION — CASES.  333 

drum  membranes  of  normal  density  and  tension.  I  may  also 
remark,  that  I  have  seen  erysipelas  of  the  face  of  a  severe  type, 
occur  in  the  course  of  acute  suppuration  of  the  middle  ear.  This 
is,  of  course,  a  serious  complication,  but  as  yet  I  have  seen  no 
fatal  results  from  it.  More  will  be  said  of  this,  in  the  chapter 
upon  "Diseases  of  the  Mastoid." 

The  following  cases  may  be  said  to  be  fairly  typical,  and  to 
show  the  ordinary  course  of  the  different  forms  of  acute  sup- 
puration of  the  middle  ear. 

CASE  I. — Acute  Suppuration  from  Scarlet  Fever — Loss  of  the  Malleus  of  each 
Side — Reproduction  of  the  Membrana  Tympani — Great  Improvement  in  Hearing 

Power. — Harry ,  aged  nine.  On  February  27,  1872,  I  was  called  by  Dr.  G. 

S.  Winston,  to  see  the  grandchild  of  a  gentleman  of  this  city,  in  regard  to  whose 
case  I  had  already  given  advice  by  mail  and  telegraph.  The  histoiy  was  as  fol- 
lows :  The  boy  had  gone  back  to  his  school,  after  spending  the  Christmas  holi- 
days at  home,  in  quite  as  good  health  as  usual ;  but  soon  after  arriving  he  was 
attacked  with  scarlet  fever,  which  rapidly  assumed  a  very  severe  type,  so  that 
his  throat  was  inflamed  and  the  cervical  glands  were  swelled,  and  the  lining 
membrane  of  the  middle  ears  was  in  a  state  of  very  acute  inflammation.  In 
spite  of  prompt  and  energetic  treatment  by  the  physician  of  the  school,  sup- 
puration occurred  in  a  few  hours.  After  the  aural  symptoms  occurred,  the  dis- 
charge of  pus  became  profuse,  so  that  the  ears  needed  cleansing  every  half 
hour.  The  malleus  bone  of  each  ear  escaped  in  the  pus,  and  I  have  them  in 
my  possession.  When  the  severest  aural  symptoms  had  subsided,  astringents 
were  used  in  the  auditory  canal,  and  the  Eustachian  tubes  treated  by  Politzer's 
method.  • 

As  soon  as  the  little  patient's  general  condition  would  allow,  he  was  returned 
to  his  home,  and  in  a  deplorable  condition.  His  ears  were  discharging  thick, 
offensive  pus,  in  such  quantities,  that  it  was  only  by  the  greatest  diligence  in 
cleansing  that  they  could  be  kept  clean  ;  the  naso-pharyngeal  space  was  secret- 
ing muco-purulent  material  in  great  masses.  The  hearing  power  was  so  much 
impaired  that  it  was  only  by  speaking  in  a  distinct  and  loud  tone,  close  to  the 
little  fellow's  ear,  that  he  could  be  made  to  understand  what  was  said  to  him. 

The  family  and  friends  believed  that  he  would  become  the  inmate  of  a  deaf 
and  dumb  asylum.  Indeed,  a  gentleman— a  friend  of  the  family — who  had  a 
child  that,  having  lost  her  hearing  from  the  scarlet  fever,  had  learned  the 
method  of  speech  by  watching  the  lips,  came  to  see  Harry,  and  urged  that  very 
prompt  measures  should  be  taken  to  cause  him  to  learn  lip  reading,  inasmuch 
as  he  felt  certain  that  he  would  never  hear  sufficiently  to  retain  his  speech.  I 
at  once  instructed  the  family  to  converse  regularly  with  the  little  patient,  to 
read  aloud  to  him,  and  to  urge  him  to  continue  to,  talk,  while  the  local  and 
general  treatment  were  carried  on.  This  they  did  with  a  remarkable  faithful- 
ness, so  that  the  boy,  hearing  what  was  said  to  him,  never  acquired  an  un- 
natural tone  of  voice. 

On  examination  it  was  found  that  the  membrana  tympani  of  each  side  was 
gone,  and  that  the  cavity  of  the  tympanum  was  filled  up  with  granular  mucous 
membrane.  The  hearing  distance  for  the  watch  was  •&  on  each  side.  The 
voice  of  a  person  speaking  with  great  distinctness  was  heard  two  feet  from  the 


334  ACUTE  SUPPURATION—  CASES. 

left  ear,  and  one  from  the  right.  Air  could  be  forced  through  both  Eustachian 
tubes.  The  patient's  general  condition  was  fair ;  but  he  was  suffering  from 
some  abdominal  effusion.  Dr.  T.  F.  Cock  was  called  in  on  this  account,  and 
ordered  the  tincture  of  the  sesquichloride  of  iron.  The  weather  being  cold,  the 
boy  was  kept  in  the  house,  and  in  a  warm  room  ;  while  a  thorough  local  treat- 
ment was  entered  upon.  The  ears  were  syringed  by  some  member  of  the  family 
every  hour  during  the  day,  if  necessary  ;  while  I  visited  him  at  first  twice,  and 
subsequently  once  a  day,  and  cleansed  the  ears  with  the  syringe  and  cotton- 
holder,  inflated  the  ears  by  Politzer's  method,  and  applied  a  solution  of  nitrate  of 
silver,  of  the  strength  of  forty  grains  to  the  ounce,  to  the  cavity  of  the  tympanum. 
The  family  applied  a  weak  solution  of  sulphate  of  zinc  in  the  evening.  The 
naso-pharyngeal  space  was  cleansed  by  the  use  of  chlorate  of  potash.  A  weak 
solution  of  Labarraque's  solution  of  chlorinated  soda  was  used  in  the  water 
employed  for  syringing  the  ear,  in  order  to  diminish  the  fetid  odor  of  the  pus. 
Under  this  treatment  the  patient. steadily  improved  until  the  discharge  of  pus 
had  entirely  ceased  from  the  left  ear,  and  a  membrana  tympani  had  formed  at 
the  bottom  of  the  canal,  with  a  small  central  aperture,  and  in  the  right  there 
was  also  a  membrane,  with  a  larger  opening,  and  a  very  slight  muco-purulent 
discharge.  On  May  llth,  about  three  months  and  a  half  from  his  return  to  the 
city,  and  about  five  months  from  the  breaking  out  of  the  scarlet  fever,  he  conld 
hear  the  voice,  with  his  face  away  from  the  speaker,  for  a  distance  of  twenty  feet, 
and  the  watch,  R.  E.,  -fg;  L.,  ^.  He  returned  to  school  in  good  general  health. 

January  9,  1873. — He  still  continues  at  school,  with  heaving  power  the  same 
as  last  noted.  The  membrana  tympani  of  left  ear  is  entirely  closed.  In  the 
right  there  is  still  a  small  opening,  and  occasionally  a  discharge  of  pus.  The 
ear  is  carefully  cleansed  at  school,  an  astringent  is  still  used,  and  Politzer's 
method  of  inflation  is  occasionally  practised. 

May,  1890. — The  patient  is  now  in  active  business  life ;  one  ear  suppurates 
considerably.  His  hearing  is  fairly  good. 

The  above  case  illustrates  what  can  be  done  for  one  of  the 
severest  cases  of  acute  suppuration  in  the  middle  ear,  resulting 
from  the  pharyngeal  inflammation  of  scarlet  fever.  Hundreds 
of  such  subjects  have  become  inmates  of  deaf  and  dumb  asy- 
lums, and  are  consequently  educated  in  a  necessarily  imperfect 
manner.  This  boy,  although  under  some  obstacles,  has  been 
educated  exactly  as  are  his  fellows,  who  enjoy  good  hearing 
power. 

CASE  II. — Acute  Suppuration  of  the  Middle  Ear,  occurring  in  a  Child,  in  Con- 
nection with  the  Whooping-cough — Membranes  Healed  in  about  a  Month. — March 

12,  1872.— Eugene ,  %aged  one,  a  rather  delicate  child,  who  is  passing 

through  the  whooping-cough.  A  few  days  ago  the  child  cried  very  much  for 
some  hours,  and  then  a  discharge  of  pus,  mingled  with  blood,  was  found  from 
each  auditory  canal.  The  spasms  of  coughing  are  very  severe.  I  was  called  to 
see  the  little  patient  a  few  days  after  the  discharge  of  pus  occurred,  and  I  found 
on  examination  that  both  membrane  tympani  were  ruptured,  and  that  consider- 
able pus  was  being  secreted  in  the  cavity  of  the  tympanum.  There  was  also 
some  naso-pharyngeal  catarrh. 

The  following  treatment  was  entered  upon:  The  ears  were  syringed  three 


ACUTE   SUPPUBATIOX — CASES.  335 

times  a  day,  with  lukewarm  water,  and  a  solution  of  sulphate  of  zinc,  gr.  ij. 
ad  5  ]'•>  was  afterward  dropped  into  the  meatus,  and  kept  there  for  a  few  minutes. 
I  saw  the  patient  three  times  a  week,  and  cleansed  the  ear  myself.  On  April 
15th,  or  a  little  more  than  a  month  from  the  time  the  perforation  occurred,  both 
drum. -heads  had  healed  and  the  discharge  had  ceased. 

CASE  III. — Acute  Suppuration  in  the  Course  of  Chronic  Nasal  Catarrh — Para' 
centesis  of  the  Membrana  Tympani. — March  13, 1873. — George  S ,  aged  thirty- 
four.  He  has  had  "catarrh"  for  two  years,  for  which  he  has  been  in  the  habit 
of  using  injections  through  the  nostrils  by  means  of  Davidson's  syringe.  For 
the  past  few  hours  he  has  had  a  pain  in  the  ears,  but  more  particularly  in  the 
left,  and  he  cannot  he.ar  well. 

An  examination  shows  that  the  patient  has  a  severe  form  of  naso-pharyngeal 
inflammation,  attended  by  a  profuse  and  fetid  secretion.  The  hearing  distance 
is,  E.  E.,  -/g-;  L.  E.,  $r.  The  right  membrana  tympani  is  sunken  and  red.  The 
left  membrane  is  very  convex  ;  a  delicate  pink  tint  involves  the  whole  surface, 
and  there  is  no  trace  of  the  handle  of  the  malleus  nor  of  the  light  spot. 

The  membrane  was  immediately  incised  in  the  upper  and  posterior  quadrant, 
and  a  small  amount  of  pus  was  evacuated.  The  ears  were  inflated  by  Politzer's 
method,  and  the  auditory  canals  syringed  with  tepid  water.  A  leech  was  applied 
upon  the  tragus  of  the  right  ear.  A  profuse  suppuration  occurred  in  the  left 
ear ;  but  it  was  soon  checked  by  the  use  of  a  solution,  gr.  xl.  ad  §  j.,  of  nitrate  of 
silver  painted  over  the  drum-head,  and  the  patient  disappeared  from  observation, 
with  the  hearing  distance  if  on  each  side,  on  March  22d,  or  nine  days  from 
the  date  of  the  first  visit.  I  afterward  learned  that  he  considered  himself 
entirely  well. 

CASE  IV. — Inflammation  of  Auditory  Canal  extending  to  the  Membrana  Tym- 
pani— Paracentesis — Cure. — Mrs.  G ,  aged  about  thirty-five.  On  April  16, 

1872,  I  was  sent  for,  by  request  of  Professor  T.  G.  Thomas,  to  see  this  patient, 
who  had  been  suffering  for  a  week  or  two  from  occasional  attacks  of  severe  pain 
referred  to  the  depth  of  the  right  ear.  These  attacks  had  been  alleviated  by  the 
application  of  leeches,  but  the  pain  continued  to  recur,  especially  at  night,  so 
that  the  patient  was  unable  to  sleep.  I  found  the  lady  suffering  very  much, 
and  she  had  been  awake  with  pain  all  night.  The  auditory  canal  was  found  to 
be  swelled,  and  there  were  two  points  of  suppuration  in  the  cartilaginous  part 
of  the  meatus.  The  membrana  tympani  was  red,  but  its  whole  surface  could  not 
be  seen  on  account  of  the  swelling  of  the  canal.  The  auditory  canal  was  scari- 
fied at  two  points,  and  the  use  of  the  douche  ordered  every  hour ;  iV  gr.  of  sul- 
phate morphia  was  ordered  to  be  taken  every  hour,  until  the  pain  was  relieved. 
In  the  evening  the  pain  not  being  markedly  relieved,  two  leeches  were  ordered 
to  be  applied  to  the  ear — one  on  the  tragus,  the  other  at  the  glenoid  fossa. 
This,  with  the  continuation  of  the  morphia,  quieted  the  pain  very  much  ;  but, 

on  the  19th,  I  was  called  early  in  the  morning,  to  find  that  Mrs.  G had  had 

a  recurrence  of  the  pain,  and  that  she  was  suffering  very  much.  I  then  made  a 
paracentesis  of  the  drum  membrane,  although  the  swelling  of  the  canal  was  so 
great  that  I  could  only  judge  of  the  fact  of  my  instrument — a  cataract  needle — 
having  passed  through  the  membrane,  by  the  depth  to  which  it  penetrated,  and 
the  yielding  sensation  communicated  to  the  fingers  as  the  needle  passed  through 
the  drum-head.  Immediate  and  great  relief  from  the  pain  was  experienced,  and 


336  ACUTE   SUPPURATION — CASES. 

the  patient,  under  the  continuation  of  the  douche,  daily  syringing,  the  use  of 
Politzer's  method  of  inflation,  on  May  llth  she  had  fully  recovered  her  hearing 
power  with  a  moderate  amount  of  suppuration. 

I  am  not  able  to  decide  whether  this  case  was  primarily  one 
of  otitis  externa,  or  otitis  media.  I  am  inclined  to  think  that  it 
was  one  of  the  former,  and  that  the  inflammatory  process  ex- 
tended to  the  membrana  tympani  from  without.  I  suppose  that 
the  membrane  was  unusually  thick,  perhaps  from  a  previous 
morbid  process,  and  that  this  accounts  for  its  continuing  intact 
for  a  longer  time  than  usual,  although  a  membrana  tympani 
that  is  invaded  by  disease  from  the  auditory  canal,  will  with- 
stand an  inflammatory  action  without  rupture  much  longer, 
than  one  whose  mucous  layer  is  the  first  affected. 

CASE  V. — Acute  Suppurative  Otitis  Media  of  some  days1  standing,  Cured  by  one 
Application  of  a  Forty -grain  Solution  of  Nitrate  of  Silver. — February  16,  1873. — 

C.  C ,  aged  one  year.     I  was  asked  to  see  this  little  patient  by  Dr.  C.  C.  Lee. 

There  had  been  .an  acute  naso-pharyngeal  catarrh  for  some  time,  and  for  a  few 
days  there  had  been  a  purulent  discharge  from  the  left  ear.  On  examination 
the  drum  membrane  was  found  to  be  perforate,  and  there  was  a  profuse  discharge 
of  pus.  The  ear  was  kept  carefully  cleansed,  and  a  warmed  solution  of  sulphate 
of  zinc  poured  into  it ;  but  it  did  not  yield  in  a  day  or  two,  when  a  solution  of 
nitrate  of  silver,  of  forty  grains  to  the  ounce,  was  brushed  over  the  canal  and 
the  perforated  membrana  tympani.  At  my  nex't  visit,  the  morning  after  this 
application  was  made,  the  discharge  had  completely  ceased,  and  the  membrana 
tympani  had  healed. 

The  foregoing  cases,  illustrate  the  ordinary  type  of  acute  sup- 
puration occurring  in  subjects  of  different  ages*.  The  practi- 
tioner who  has  not  seen  much  of  aural  disease,  may  be  at  a  loss 
when  called  to  a  case  of  acute  suppuration  of  the  ear,  to  know 
whether  its  seat  is  in  the  auditory  canal  or  the  middle  ear.  The 
parts  should  be  carefully  cleansed  of  pus  before  a  decision  is 
made,  although  it  should  be  borne  in  mind,  as  was  stated  in  the 
chapter  on  ''Acute  Affections  of  the  Canal,"  that  suppuration  in 
the  middle  ear  is  much  more  frequent  than  the  same  process  in 
the  external  auditory  canal.  Indeed,  an  acute  diffuse  suppura- 
tion of  the  external  ear  is  an  extremely  rare  disease.  If  an  open- 
ing in  the  drum-head  cannot  be  detected  by  the  otoscope,  the 
performance  of  the  Valsalvian  experiment  by  the  patient,  or  the 
employment  of  Politzer's  method,  and  a  subsequent  inspection, 
will  determine  the  question.  If  the  membrane  be  perforate,  the 
air  will  be  heard  to  whistle  through  the  aperture,  and  an  air- 
bubble,  made  by  the  pus  or  mucus,  will  be  found  at  the  seat  of 
the  aperture.  The  presence  of  an  air-bubble,  before  the  parts 
have  been  cleansed,  is  not,  as  Wilde  thought,  a  pathognomonic 


SEKOUS   INFLAMMATION.  337 

symptom  of  a  perforation,  for  I  have  seen  this  bubble  when  the 
membrane  was  intact,  but  fluid  was  lying  upon  it. 


SEROUS  INFLAMMATION  OF  THE  MIDDLE  EAR. 

An  increased  secretion  of  the  middle  ear,  is  not  always  either 
of  a  catarrhal  or  a  purulent  character.  As  has  been  observed  in 
the  account  of  the  anatomy  of  this  part,  its  lining  membrane 
sometimes  assumes  the  character  of  a  serous  membrane.  In 
like  manner  an  excessive  secretion  in  the  middle  ear  may  be,  in 
exceptional  cases,  predominantly  or  entirely  of  a  serous  char- 
acter. This  may  occur  when  the  membrana  tympani  is  sound, 
and  also  during  the  course  of  a  suppurative  process.  The  mem- 
*brana  tympani,  if  entire,  has  an  unmistakable  appearance,  when 
serum  is  collected  behind  it  in  great  quantity.  It  is  somewhat 
bulging,  and  through  its  transparent  layers  may  be  detected  a 
yellowish  fluid,  which  may  be  caused  to  change  its  position  by 
movements  of  the  head,  just  as  hypopyon  may  be  made  to 
change  its  position  in  the  anterior  chamber  of  the  eye.  The 
subjective  symptoms  of  this  accumulation,  like  those  from  the 
accumulations  of  mucus,  are  sometimes  very  annoying  and 
trying,  without  being  absolutely  painful.  The  movement  of 
the  serum  is  felt  by  the  patient  at  each  considerable  change 
in  position,  especially  on  rising  from  lying  down,  and  some- 
times the  sound  of  his  voice  becomes  very  distressing,  and  even 
"echo"  hearing  and  double  hearing  may  be  present,  just  as  it 
may  be  when  mucus  has  accumulated  in  the  ear  in  sub-acute 
catarrh.  The  hearing  power  is  very  much  affected  in  these 
cases,  but  it  may  be  variable,  according  as  the  serous  fluid  has 
changed  its  position.  Great  pain  is  sometimes  spoken  of  by 
patients,  but  this  is  usually  in  neurotic  or  hysterical  subjects, 
for,  from  all  I  can  learn,  while  the  presence  of  serum  in  the 
middle  ear  causes  very  annoying  and  disturbing  sensations, 
they  are  not  to  be  compared  in  severity  with  those  from  the 
accumulation  of  mucus,  blood,  or  pus.  Dr.  Tansley '  reported  a 
case  of  serous  inflammation  of  the  middle  ear,  occurring  in  a 
woman  of  advanced  age,  and  because  his  case  was  not  marked 
by  severe  pain,  he  proposes  to  divide  these  cases  into  two  classes, 
inflammatory  and  non-inflammatory.  To  the  latter  he  gives  the 
name  of  hydro-tympanum.  This,  I  think,  is  a  needless  and  un- 
necessary refinement  in  nomenclature,  which  may  possibly  lead 
to  a  confusion  of  ideas.  Some  cases  of  serous  inflammation  of 
the  middle  ear  are  attended  by  pain,  and  others  are  not,  just  as 


1  Archives  of  Clinical  Surgery,  July  25,  1878. 
22 


SEROUS   INFLAMMATION. 

we  may  have  a  painless  suppuration  of  the  middle  ear.  But  as 
I  have  already  observed,  annoying  as  is  a  serous  inflammation 
of  the  tympanum,  it  is  not  usually  painful  in  the  same  sense 
that  acute  catarrh  or  suppuration  are  found  to  be.  As  has  been 
already  said,  an  accumulation  of  serous  fluid  in  the  tympanum 
may  occur  in  the  course  of  a  suppurative  process,  and  it  may  be 
added,  that  it  is  very  difficult  to  manage  from  the  rapid  reac- 
cumulation  of  the  serum.  Serous  accumulations  are  apt  to  oc- 
cur, in  my  experience,  in  debilitated  subjects.  The  inflamma- 
tion may  be  considered,  I  think,  as  of  a  bastard  type. 

Dr.  C.  H.  Burnett '  reports  a  case  of  repeated  accumulations 
of  serous-like  fluid,  in  the  tympanum  of  a  man  fifty-five  years 
of  age.  The  membrana  tympani  was  opened  thirty-seven  times 
by  Dr.  Burnett  in  nine  years,  and  always  with  relief  to  the  pa-* 
tient.  In  an  obstinate  case  of  this  kind,  I  once  made  as  many  as 
five  openings  in  the  drum-head  in  a  few  weeks.  The  patient 
was  a  very  nervous  woman  of  some  fifty  years  of  age,  and  al- 
though she  got  relief  at  every  operation,  it  was  temporary,  and 
she  sought  other  advice.  Burnett  entitles  his  case  dropsy  of  the 
middle  ear. 

Treatment. — Paracentesis  of  the  drum-head  is  often  indicated 
in  cases  of  serous  accumulation,  although  at  times  the  fluid  may 
disappear  under  the  treatment  of  the  middle  ear  by  inflation. 
At  the  same  time,  the  general  health  will  need  careful  looking 
after.  Generally,  paracentesis  must  be  repeatedly  performed 
in  the  same  case  before  a  cure  results.  Delstanche's  masseur 
will  be  found  very  useful  in  drawing  the  serous-like  fluid, 
or  serum,  or  tenacious  mucus,  from  the  tympanum.  Of  the 
accumulation  of  serum  and  mucus  in  chronic  cases,  more  will 
be  said  in  an  appropriate  chapter.  Leeches  and  the  warm 
douche  are  of  little  or  no  avail  in  serous  inflammation,  but  the 
use  of  gargles  is  strongly  indicated.  By  them,  the  action  of  the 
Eustachian  tube  and  the  consequent  passage  of  the  fluid  from 
the  tympanum  to  the  pharynx,  are  promoted. 


American  Journal  of  the  Medical  Sciences,  January,  1884,  p.  122. 


CHAPTER  XIII. 

CHRONIC   NON-SUPPURATIVE    INFLAMMATION    OF    THE    MID- 
DLE EAE. 

Frequency  of  this  Disease. — Nomenclature. — Catarrh. — Proliferous  Inflammation. — 
Subjective  Symptoms.  —  Vertigo.  —  Tinnitus  Aurium.  —  Insanity.  —  Subjective 
Symptoms  of  Proliferous  Inflammation. — Objective  Symptoms. — Impairment  of 
Hearing. — Changes  in  the  Membrana  Tympani. — Eustachian  Tube. — Naso-Phar- 
yngeal  Inflammation. — Adenoid  Growths. — Pathology. — Causes. 

IT  has  been  a  common  reproach  both  from  the  profession  and 
the  laity,  that  the  treatment  of  aural  disease  is  unsuccessful.  In 
1870  one  of  the  Boylston  prize  questions  was  as  follows  :  ''Crit- 
icisms on  the  recent  opinion  of  a  medical  writer  that  the  less 
serious  diseases  of  the  ear  may  be  successfully  treated  by  a  well- 
qualified  general  practitioner,  and  the  more  serious  affections 
by  none."  When  Von  Troltsch,  announced  his  intention  to  de- 
vote himself  to  the  study  and  treatment  of  aural  disease,  one  of 
his  professional  friends  warned  him  that  he  might  put  his  good 
name  in  jeopardy.  These  incorrect  ideas  have  arisen  chiefly 
from  ignorance  as  to  the  nature  and  causes  of  diseases  of  the 
ear.  There  is  a  large  class  of  cases  in  this  department  of  medi- 
cine, that  at  the  very  best  can  only  be  alleviated,  and  can  never 
be  cured.  But  many  of  these,  have  reached  such  a  classification 
from  a  point  where  treatment  would  have  been  of  the  greatest 
avail.  The  prevention  of  a  chronic  aural  affection  is  often  with- 
in the  power  of  every  practitioner,  while  it  once  having  become 
established,  its  cure  is  impossible.  After  many  years  of  careful 
study  of  diseases  of  the  ear,  I  think  it  may  be  said  that  there 
are  but  two  classes  of  cases  of  aural  disease  in  which  we  may 
not  expect  very  good  results  from  treatment  and  care.  Nearly 
all  the  others  are  singularly  tractable,  when  their  course  is 
properly  regulated. 

By  these  two  classes  I  mean  chronic  non-suppurative  inflam- 
mation of  the  middle  ear,  and  the  affections  of  the  labyrinth, 
or  internal  ear. 

Of  every  thousand  cases  of  aural  disease  about  three  hun- 


340  CHRONIC   NON-SUPPURATIVE   INFLAMMATION. 

dred  belong  to  the  former  class,  while  but  a  small  percentage  of 
disease  of  the  internal  ear  occurs. 

Chronic  non-suppurative  inflammation  of  the  middle  ear,  is 
so  insidious  in  its  origin  and  progress,  that  it  may  have  existed 
for  months  and  years  before  its  subject  is  aware  of  it,  and  brings 
himself  under  professional  care.  It  may  impair  or  nearly  de- 
stroy the  hearing,  with  but  few  of  the  subjective  evidences  of 
what  is  called  inflammation — there  may  be  no  heat,  redness,  or 
pain — but  we  find  many  of  the  other  marks  of  diseased  action, 
in  swelling,  thickening,  adhesions,  which  entitle  it  to  be  placed 
under  this  head.  It  has  also  been  called  a  catarrhal  inflamma- 
tion, because  the  cavity,  air-chamber,  and  tube,  which  form  its 
seat,  are  lined  by  mucous  membrane.  We  say  middle  ear,  be- 
cause these  parts  form  the  anatomical  centre  of  the  organ  of 
hearing.  It  is  the  same  disease  which  Sir  William  Wilde  under- 
stood, but  which,  as  it  seems  to  me,  he  inappropriately  called 
chronic  myringitis,  or  inflammation  of  the  drum-head.  But  the 
drum-head  is  only  one  of  other  parts  that  is  affected  in  this  dis- 
ease, and  may,  perhaps,  be  scarcely  at  all  injured,  while  the 
most  important  changes  in  structure  and  function  have  occurred 
in  other  parts  of  the  middle  ear.  In  common  speech — and  I  do 
not  mean  by  this,  among  the  laity,  but  in  the  profession — many 
of  the  forms  of  chronic  non-suppurative  inflammations  of  the 
middle  ear,  have  been,  from  time  immemorial,  classified  as  ner- 
vous. The  great  author  whom  I  have  just  quoted,  did  much  to 
combat  this  error — an  error  which  not  only  kept  back  the  growth 
of  the  science  of  otology,  because  it  retarded  the  conception  of  a 
successful  plan  of  treatment,  but  which  also  assisted  to  deepen 
the  reproach  which  for  centuries  has  rendered  aural  disease 
the  bete  noir  of  medical  practice. 

The  reason  for  this  classification  of  these  affections  as  ner- 
vous is  found  in  the  fact  that  the  poor  means  of  diagnosis, 
which  were  in  the  hands  of  the  profession  until  a  few  years 
since,  the  absence  of  a  simple  otoscope,  and  the  want  of 
knowledge  of  the  value  of  the  Eustachian  catheter,  and  the 
tuning-fork,  did  not  allow  of  the  appreciation  of  the  delicate 
changes  which  make  up  what  the  Germans  call  the  "  Krank- 
heitsbild  " — the  picture  of  the  disease.  There  was  another  rea- 
son in  the  fact  that  the  poor,  distressed  patient,  having  gone  in 
vain  to  his  usual  consolers,  if  not  curers — the  regular  practi- 
tioners— often  resorted  to  the  charlatan.  Under  his  wonderful 
but  distressing  treatment,  added  to  the  trial  of  the  horrible  tin- 
nitus aurium,  and  impairment  of  hearing,  he  became  so  utterly 
worn  out  and  so  distrustful  of  each  new  adviser,  that  the  so- 
called  nervousness  was  very  apparent. 


NON-SUPPUKATIVE  INFLAMMATION. 


341 


The  common  idea  of  nervous  deafness  is  that  it  occurs  chiefly 
among  the  weak  and  sensitive  ;  but  this  notion  has  no  basis  in 
pathology — so-called  nervous  people  are  not  apt  to  be  deaf,  nor 
does  their  sensitive  or  nervous  organism  have  much  effect  upon 
their  hearing  power,  unless  it  is  already  impaired  from  an  in- 
flammatory cause. 

As  yet.  this  class  of  cases  comes  as  a  rule  to  the  notice  of  the 
practitioner  of  modern  otology,  only  when  the  disease  is  far  ad- 
vanced. 

The  following  table  shows  this.  It  is  compiled  from  the  first 
cases  of  this  disease  that  were  observed  by  me  in  private  practice: 

Cases  of  Chronic  Non-suppurative  Inflammation. 

Number  of  cases  of  80  years'  standing 1 

over  40  years'  standing 6 

over  20     "           "         40 

between  10  and  20  years'  standing 133 

Sand  10     "            "        141 

3  and    5      "            "        75 

1  and    3     "            "        74 

one  year's  standing 42 

less  than  one  year's  standing 13 


Total 525 

It  will  be  seen  that  by  far  the  larger  number,  more  than  fifty 
per  centum,  had  observed  some  loss  of  function  for  more  than 
five  years,  while  about  eight  per  cent,  had  been  affected  for  more 
than  twenty  years. 

I  add  a  second  table  made  from  the  last  five  hundred  and  ten 


cases 


Cases  of  50  years'  duration 1 

40     "            "          5 

30  to  40  years'  duration 6 

20  to  30     "            "         30 

15  to  20     "            "         27 

10  to  15     "            "         77 

5  to  10     "            "         112 

4  years'  duration 43 


3     " 

2  " 

1  year's 
6  months' 

3  " 


53 
76 
41 

18 
21 


Total 510 

It  will  be  seen  that  even  in  the  second  table  the  proportion  of 
cases  of  from  five  to  twenty  years'  standing  is  very  large,  nearly 


342  CHROMIC   NON-SUPPURATIVE   INFLAMMATION. 

one  half  of  the  whole  number,  but  there  is  a  gratifying  increase 
in  the  number  of  those  that  have  existed  less  than  one  year. 

Every  person  has,  so  to  speak,  a  superfluous  amount  of  hear- 
ing, which  he  may  lose  before  his  hearing  is  sufficiently  impaired 
to  annoy  him  in  the  common  affairs  of  life.  People  who  spend 
many  hours  of  the  day  in  noisy  places,  such  as  boiler-shops,  on 
board  steamships,  in  the  stock-board  of  Wall  Street,  as  I  have 
seen  by  frequent  examples,  may  lose  very  much  of  their  hearing 
power  before  they  are  at  all  aware  of  it.  Then,  again,  the  lower 
classes,  who  labor  har.d  all  day  in  the  open  air  with  their  fellows, 
and  who  live  at  night  in  small  and  noisy  rooms,  where  the 
demands  upon  the  hearing  power  are  very  slight,  hardly  con- 
sider its  impairment  as  a  loss  of  function. 

Besides  all  this,  people  in  general,  who  have  no  scruples  about 
confessing  to  impaired  eyesight,  very  reluctantly  admit  a  loss 
of  hearing.  It  thus  becomes  very  difficult  in  many  cases  to  say 
when  an  impairment  of  hearing  was  first  observed. 

These  causes  have  conspired,  with  the  general  ignorance  of 
the  pathology  and  treatment  of  non-suppurative  aural  disease, 
to  render  the  results  of  treatment  unsatisfactory,  as  well  as  to 
cause  patients  to  consult  a  physician  at  a  very  late  stage  of  their 
trouble. 

I  have  never  been  fully  satisfied  with  the  nomenclature  of 
Von  Troltsch,  vast  improvement  as  it  was  on  those  classifica- 
tions which  had  preceded  it.  Some  of  them  were  crude,  others 
fanciful  and  altogether  too  refined.  Von  Troltsch,  classified  all 
non-suppurative  disease  as  catarrhal,  and  then  separated  those 
in  which  the  catarrhal  symptom — excess  of  secretion — was  not 
very  marked,  by  placing  them  under  the  head  of  sclerosis  or 
hardening  or  rigidity  of  the  mucous  membrane.  After  looking 
at  many  ears,  in  which  there  was  no  trace,  either  in  the  pharynx, 
Eustachian  tube,  or  cavity  of  the  tympanum,  of  an  excess  of 
secretion  from  the  mucous  membrane,  but  in  which  there  were 
marked  changes  in  the  way  of  increase,  hypertrophy  or  prolifera- 
tion of  tissue,  and  in  others  where  the  catarrhal  symptoms  were 
very  much  in  the  background,  although  they  existed,  I  felt  that 
aural  catarrh  was  a  meagre  and  incorrect  name  with  which  to 
describe  such  a  state  of  things.  The  very  name  "catarrh,"  as 
applied  to  an  ear  with  a  sunken  drum-head,  immovable  chain  of 
bones,  dry  pharynx,  easily  permeable  Eustachian  tubes,  is  repug- 
nant to  all  our  notions  of  scientific  nomenclature.  Whatever 
may  have  been  the  origin  or  exciting  cause  of  such  cases,  they 
cannot  be  called  catarrhal,  when  their  examination  shows  such 
a  state  of  things  as  this.  t  ns 

Gruber  has  made  a  division  in  his  text-book,  and  describes 


CATAERHAL   AND    PROLIFEROUS   FORMS.  343 

an  otitis  media  hypertrophica,  or  plastic  inflammation  ;  but  I 
think  his  own  description  of  the  pathology  of  the  disease  shows 
that  he  is  discussing  not  what  has  hitherto  been  comprehended 
under  the  head  of  sclerosis,  but  an  extension  of.  a  suppurative 
process,  such  as  causes  the  formation  of  granulations  or  polypi. 
This  criticism  has  also  been  made  by  Politzer. 

My  classification  is  founded  upon  clinical  experience,  and 
upon  the  reports  of  the  pathology  of  this  class  of  cases  that  have 
been  made  by  Toynbee,  and  others. 

Chronic  non-suppurative  inflammations  of  the  middle  ear 
may  be  divided  into  two  great  classes, 

Catarrhal, 
Proliferous. 

I  choose  the  translation  of  the  German  word  wucherung,  as 
furnishing  the  best  term  to  describe  the  changes  in  the  middle 
ear,  of  which  I  am  to  speak ;  and  in  what  I  have  to  say,  I  shall 
attempt  to  be  guided  by  these  divisions. 

Since  the  publication  of  the  first  edition  of  this  work,  the  term 
chronic  non-suppurative  inflammation,  has  been  widely  adopted 
in  Great  Britain  as  well  as  in  this  country,  and  some  authorities 
have  also  accepted  the  term  proliferous,  in  the  sub-classification. 

Some  authors  and  practitioners  would  admit  another  classifi- 
cation, based  upon  the  parts  involved,  and  speak  of  chronic 
myringitis,  or  chronic  inflammation  of  the  membrana  tympani, 
of  the  tympanum,  and  of  chronic  catarrh  of  the  Eustachian  tube. 
Whatever  we  may  believe  of  acute  inflammation  of  these  parts, 
I  can  scarcely  accept  the  idea  of  one  that  has  existed  for  any 
considerable  space  of  time  without  involving  either  the  cavity  of 
the  tympanum  or  the  mastoid  cells,  or  both.  The  nomenclature, 
tubal  catarrh,  also  leads,  as  I  believe,  to  incorrect  notions  as 
to  the  therapeutic  value  of  the  Eustachian  catheter,  and  of  Po- 
litzer's  method  of  inflating  the  drum  cavity-.  These  methods  of 
treatment  are  useful,  not  so  much  for  what  they  do  to  the  tube, 
as  for  their  effect  upon  the  cavities  into  which  it  opens.  When 
air-bubbles  are  crackling  in  the  cavity  of  the  tympanum,  as  in 
catarrhal  inflammation,  or  when  the  tube  is  greatly  narrowed 
by  the  hypertrophy  of  its  lining  membranes,  but  at  the  same 
time  we  have,  as  we  always  do,  in  the  latter  case,  a  sunken 
drum-head,  an  altered  light  spot,  signs  of  proliferous  inflamma- 
tion of  many  of  the  structures  making  up  the  middle  ear,  I  do 
not  see  how  we  can  with  propriety  speak  of  a  tubal  affection, 
even  if  its  symptoms  are  predominant,  and  even  if  treatment  of, 
and  through,  the  lining  membrane  of  the  tube,  does  place  things 
in  such  a  condition  that  Nature  will  complete  the  cure.  No  time 
need  be  spent  upon  this  question,  which  may,  perhaps,  seem  to 


344  CHRONIC   CATARRHAL   INFLAMMATION. 

some  a  comparatively  unimportant  one,  had  not  incorrect  notions 
in  the  past  led  to  an  incorrect  style  of  treatment.  In  former 
times,  the  membrana  tympani,  under  the  assumption  that  such 
an  affection  as  an  independent  chronic  myringitis  existed,  was 
vigorously  treated  by  instillations  of  various  fluids,  and  by  per- 
foration, and  of  late,  under  the  idea  that  we  have  a  great  deal 
of  tubal  catarrh  without  further  progress  in  the  morbid  action, 
undue  stress  is  sometimes  laid  upon  applications  to  the  mouth  of 
the  tube.  Politzer's  method  is  then  used  as  a  complete  substitute 
for  the  catheter,  when  in  my  opinion,  indispensable  as  it  is,  its 
chief  value  is  as  an  adjuvant  to  that  instrument. 

SUBJECTIVE  SYMPTOMS  OF  CHRONIC  CATARRHAL  INFLAMMATION. 

I  think  we  may  assume,  from  the  history  of  cases,  that  this 
form  of  disease  is  either  a  consequent  of  frequent  attacks  of 
acute  catarrh  of  the  middle  ear,  or  that  it  occurs  in  people  who 
have  what  we  may  call  a  catarrhal  diathesis.  Those  who  suffer 
from  hay  fever,  are  very  apt  in  time  to  be  affected  with  chronic 
catarrh  of  the  middle  ears.  The  disease  is,  therefore,  unlike  its 
companion,  proliferous  inflammation,  not  at  all  insidious  in  its 
approach.  The  patient  suffering  from  this  disease,  who  con- 
sults us  about  his  hearing,  is  usually  aware  that  there  is  an  ex- 
cess of  secretion  in  his  pharynx,  and  that  for  years  he  has  been 
annoyed  and  troubled  by  being  obliged  to  use  a  handkerchief 
very  freely,  and  by  feelings  of  fulness  referred  to  the  frontal 
sinus  and  tympanic  cavities.  There  is  often,  also,  at  times,  a 
sound  in  the  ear  like  the  crackling  of  air-bubbles.  The  voices 
of  friends  appear  muffled ;  and  it  is  hard  for  the  victims  of 
chronic  aural  catarrh,  when  the  disease  is  advancing,  not  to  be- 
lieve that  every  one  is  speaking  in  a  much  lower  tone  than  is 
usual  for  them.  Such  patients  often  complain  bitterly  on  this 
subject,  and  will  scarcely  admit  that  their  hearing  is  at  all  im- 
paired, or,  if  so,  they  stoutly  assert  that  it  is  one  ear  only,  when 
the  fact  is,  that,  with  one  perfect  ear,  it  is  only  under  peculiar 
circumstances,  certainly  not  in  ordinary  conversation,  in  front 
of  the  patient,  that  a  person  will  be  observed  to  be  at  all  hard  of 
hearing. 

There  is  a  feeling  about  this  that  is  different  from  that  ex- 
pressed about  diseases  of  the  eye  at  least,  and  I  believe,  in  most 
maladies,  patients  will  express  their  feelings,  and  often  with  an 
exaggeration,  rather  than  with  an  extenuation  of  the  symp- 
toms ;  but,  however  much  patients  with  chronic  inflammation 
of  the  middle  ear  may  suffer  from  impairment  of  hearing,  they 
will  often  insist  that  they  are  hardly  affected,  or  that  they  have 


VERTIGO   IN   DISEASE   OF  THE   MIDDLE   EAR.  345 

a  very  little  trouble  in  that  way,  when  they  can  scarcely  hear 
loud  conversation  addressed  specially  to  them. 

Patients  affected  with  chronic  catarrh  of  the  middle  ear  also 
complain,  as  a  rule,  of  tinnitus  aurium,  and  a  sense  of  fulness 
in  the  ears.  The  ears  feel  as  if  the  auditory  canals  were  stopped 
up.  They  often  ask  very  anxiously,  if  there  is  not  something  in 
the  ear,  and  seem  incredulous  when  the  negative  answer  is 
given.  Vertigo  is  another  symptom  of  which  these  patients 
sometimes  speak,  and  it  is  often  considered  as  undoubted  evi- 
dence that  there  is  disease  of  the  brain.  Vertigo  is  a  symptom 
by  no  means  peculiar  to  catarrhal  inflammation.  It  also  occurs 
in  impacted  cerumen,  and  still  more  frequently  in  proliferous 
inflammation,  as  well  as  in  affections  of  the  labyrinth  and  in 
cerebral  disease.  When  vertigo  occurs  in  aural  disease,  it  is  a 
consequence  of  increased  pressure  upon  the  labyrinth  through 
the  fenestra  ovalis  or  of  an  affection  of  the  labyrinth  or  brain. 
It  is  by  no  means  a  serious  symptom,  when  the  cause  is  to  be 
found  in  the  middle  ear,  for  it  is  usually  relieved  by  a  mechan- 
ical treatment  through  the  Eustachian  catheter.  There  are 
many  cases  in  my  note-book  which  illustrate  this,  but  none 
more  striking  than  the  following  : 

A  physician  once  consulted  me  on  account  of  impairment  of 
hearing  in  one  ear,  accompanied  by  a  tendency  to  topple  over 
on  that  side,  which  he  said  was  a  consequence  of  being  thrown 
from  his  sleigh  some  months  before,  when  he  suffered  a  concus- 
sion of  the  brain.  He  was  quite  disposed  to  regard  the  tendency 
to  fall  over,  as  a  cerebral  lesion,  but  the  use  of  the  Eustachian 
catheter  and  Politzer's  method  of  inflating  the  ear  not  only  im- 
proved the  hearing,  but  took  away  the  unpleasant  sensation. 
Physician  as  he  was,  he  was  at  first  disposed  to  smile  at  the 
idea  of  using  local  means  to  ameliorate  this  brain-symptom ; 
but  he  has  continued  to  be  perfectly  relieved  from  his  cere- 
bral malady  up  to  this  time,  ten  years  or  more  since  he  con- 
sulted me. 

The  subject  of  aural  vertigo  has  been  very  much  confused 
by  the  disposition,  especially  found  among  neurologists,  to  at- 
tach the  name  of  "Meniere's  disease"  to  every  case  of  aural 
disease  in  which  vertigo  is  a  symptom.  This  will  be  more  fully 
discussed  in  a  subsequent  chapter,  but  it  may  be  well  to  say 
here  that  vertigo  occurs  at  times  in  such  a  large  variety  of  aural 
cases,  that  it  would  be  well  to  abolish  the  name  of  Meniere's 
disease,  except  with  reference  to  those  cases  where  the  origin 
of  the  vertigo  is  undoubtedly  in  the  labyrinth,  and  where  it  is 
not  plainly  secondary  to  an  affection  of  the  auditory  canal  or 
middle  ear.  As  now  used  it  describes  nothing,  and  leads  to 


346  INSANITY   FROM    AURAL   DISEASE. 

want  of  exactness  in  the  diagnosis.  I  have  just  dismissed  from, 
my  care  a  young  woman,  who  became  very  ill  from  acute  catarrh 
of  the  middle  ears,  accompanied  by  vertigo,  the  tendency  being 
to  pitch  forward.  By  the  use  of  leeches,  blisters,  and  inflation 
of  the  middle  ears  the  symptom  of  vertigo  was  relieved  in 
twenty-four  hours,  and  disappeared  wholly  in  two  days.  The 
leeching  and  the  inflation  both  afforded  immediate  relief. 

I  have  often  heard  patients  describe  the  feeling  of  fulness  in 
the  ears  as  a  sensation  as  if  the  ears  were  plugged  with  some 
foreign  substance  ;  it  is  almost  impossible  for  them  to  avoid  the 
impression  that  the  auditory  canals  are  plugged  with  cerumen. 
Very  many  times,  after  I  have  examined  a  patient  suffering 
from  chronic  disease  of  the  middle  ear,  I  have'been  asked  to 
look  again  to  see  whether  I  could  not  find  some  hardened  wax  ; 
and  on  one  occasion  a  poor  fellow  who  I  suppose  was,  to  a  cer- 
tain extent,  insane,  grew  very  angry  and  called  me  hard  names, 
because  I  would  not  remove  wax  which  he  knew  was  in  his  ear. 

Troltsch '  relates  a  case  from  Meyer,  of  Hamburg,  where  a 
melancholic  person  was  relieved  of  a  sound  in  the  ear,  seeming 
to  him  to  be  the  cry  of  a  child,  by  the  removal  of  a  plug  of  ceru- 
men, which  caused  deafness  on  one  side.  The  patient  made  a 
rapid  and  complete  recovery  from  the  mental  affection,  after 
the  cerumen  was  removed.  It  is  the  opinion  of  Schwartze,* 
that  subjective  aural  sensations,  which  are  caused  by  demon- 
strable affections  of  the  ear,  may,  in  predisposed  persons,  es- 
pecially when  there  is  any  hereditary  tendency  to  mental  dis- 
ease, become  the  direct  cause  of  aural  hallucinations,  that  may 
accelerate  the  outbreak  of  a  disease  of  the  brain.  He  mentions 
a  case  where,  in  his  opinion,  and  in  that  of  one  of  the  physicians 
of  the  Insane  Asylum  at  Halle,  a  threatened  attack  of  brain  dis- 
ease was  prevented  by  treatment  of  the  ear.  In  some  cases, 
insane  persons,  who  suffer  from  aural  disease,  distinguish  its 
tinnitus  from  these  illusions  or  hallucinations. 

Dr.  Koppe  confirms  this  view,  and  shows  that  in  some  cases 
hallucinations  disappear  after  treatment  of  the  ear. 

I  have  elsewhere  reported3  a  case  of  the  suicide  of  a  pro- 
fessor in  one  of  our  educational  institutions,  who  consulted  me 
on  account  of  impairment  of  hearing,  but  more  especially  on 
account  of  tinnitus  aurium.  He  said,  on  leaving  the  consulting- 
room,  that,  if  he  felt  sure  that  I  was  correct  in  my  opinion  (that 
he  would  not  get  great  relief  from  this  very  trying  symptom, 
tinnitus),  he  would  put  an  end  to  his  existence ;  which  he  did  a 

1  Text-book,  second  American  edition,  p.  531 . . 
8  Loc.  cit.,  p.  532.  3  New  York  Medical  Journal,  August,  1869. 


INSANITY   FROM   AURAL   DISEASE.  347 

few  months  after,  by  blowing  out  his  brains.  A  few  years  since 
a  gentleman,  a  public-school  teacher,  consulted  Dr.  Charles  S. 
Bull,  while  he  was  in  charge  of  my  patients,  in  regard  to  a  sup- 
puration of  the  ear,  which  caused  considerable  impairment  of 
hearing  and  great  tinnitus.  He  was  exceedingly  depressed  and 
annoyed  by  the  tinnitus.  It  is  said  that  he  committed  suicide 
on  account  of  the  depression  caused  by  this  state  of  his  ears. 
There  can  be  no  doubt  but  that  this  symptom  is  one  of  the  most 
distressing  that  can  befall  a  patient,  and  that  in  some  cases  it 
is  the  provoking  cause  of  suicide.  Again  and  again,  I  have 
satisfied  myself  that  the  great  depression,  which  is  the  rule  in 
persons  whose  hearing  is  impaired,  was  due  entirely  to  the 
aural  disease. 

Dr.  O.  D.  Pomeroy,1  of  this  city,  examined  sixty  lunatics  at 
Blackwell's  Island  Lunatic  Asylum,  and  he  found  disease  of  the 
ear  in  many  of  those  who  suffered  from  what  may  be  called 
aural  hallucinations,  although  not  in  so  large  a  proportion  as 
stated  by  Schwartze  and  Koppe. 

Dr.  C.  E.  Wright2  published  a  case  of  a  patient  in  the  In- 
diana State  Asylum  for  the  Insane,  who  attempted  to  destroy 
herself  by  putting  a  steel  button  in  her  ear.  The  patient  was 
discharged  from  the  hospital,  as  having  recovered  her  reason, 
but  became  nervous  and  despondent,  until  she  was  relieved  by 
the  removal  of  the  button  ;  and  a  dread  of  insanity  and  of  sud- 
den death,  from  which  she  suffered,  then  also  disappeared. 

Troltsch  speaks  of  confusion  of  the  intellect,  an  inability  to 
keep  up  a  connected  line  of  thought,  as  a  subjective  symptom 
of  chronic  aural  disease,  and  I  am  enabled  to  verify  this  opinion. 
Over  and  over  again,  have  patients  with  chronic  disease  of  the 
middle  ear,  not  suffering  from  pain,  but  from  tinnitus,  volun- 
tarily informed  me  that  these  noises,  together  with  the  impair- 
ment of  the  hearing,  had  a  great  effect  upon  their  mental 
powers.  On  the  other  hand,  I  have  seen  cases  where  most  suc- 
cessful men,  such,  for  instance,  as  distinguished  general  officers 
in  the  army,  and  celebrated  writers,  have  suffered  from  boy- 
hood with  chronic  inflammation  of  the  middle  ear  and  tinnitus 
aurium. 3 

The  sounds  in  the  ears,  of  which  patients  speak,  are  vari- 
ously described  ;  some  speak  of  a  ringing  of  bells,  which  is  per- 


1  Transactions  of  the  American  Otological  Society,  Fourth  Year,  p.  46. 

2  Indiana  Journal  of  Medicine,  November,  1871. 

3  The  late  Dr.  George  M.  Beard,  has  often  told  me  of  the  tinnitus  aurium  with 
which  he  was  affected.     He  had  chronic  non-suppurative  inflammation  and  described 
the  noises  in  his  head,  in  graphic  style.     They  never,  however,  dampened  his  cheerful 
and  humorous  temperament 


348  TINNITUS   AURIUM. 

haps  the  most  aggravating  form ;  others  have  likened  them  to 
the  murmur  of  trees,  the  hum  of  a  tea-kettle,  etc.  Wilde  is  un- 
doubtedly correct  in  stating  that  the  descriptions  which  patients 
give  of  the  noises  depend  to  a  certain  degree  upon  their  fancy, 
their  graphic  power  of  explanations,  and  not  unfrequently  upon 
their  rank  of  life  and  the  sounds  with  which  they  are  most  fa- 
miliar ;  thus  he  says  :  "  Persons  from  the  country  or  rural  dis- 
tricts draw  their  similitudes  from  the  objects  and  noises  by 
which  they  have  been  surrounded,  as  the  falling  and  rushing  of 
water,  the  singing  of  birds,  the  buzzing  of  bees,  and  the  waving 
or  rustling  of  trees  ;  while,  on  the  other  hand,  persons  living  in 
towns,  or  in  the  vicinity  of  machinery  or  manufactories,  say 
that  they  hear  the  rolling  of  carriages,  the  hammerings,  and  the 
various  noises  caused  by  steam-engines.  Servants  almost  in- 
variably add  to  their  other  complaints  that  they  suffer  from  the 
ringing  of  bells  in  their  ears  ;  while,  in  the  country,  old  women 
much  given  to  tea-drinking  sum  up  the  category  of  their  ail- 
ments by  saying  that  '  all  the  tea  kettles  in  Ireland  are  boiling 
in  their  ears.' ':  No  description  of  tinnitus  aurium  has  ever  sur- 
passed this  one  given  by  the  great  Irish  observer. 

Tinnitus  aurium  is  usually,  although  not  always,  a  subjec- 
tively disagreeable  symptom.  Sometimes,  however,  it  is  not 
unpleasant  to  the  patient,  but  it  may  accompany  its  subject  as 
a  pleasing  musical  concert.  One  of  my  patients,  a  young  wo- 
man having  tinnitus  aurium  as  one  of  the  symptoms  of  disease 
of  the  middle  ear,  kept  a  record  for  me  of  what  she  heard  "  in 
her  head." 

February  13th. — Morning,  C  sharp,  B  flat,  F  sharp  in  right ; 
B  in  left.  Night,  E  flat,  C  flat. 

February  14th. — Morning,  E  flat,  C  flat.  Night,  C  sharp,  B 
flat,  F  sharp. 

February  15th.— Morning,  C  sharp,  B  flat,  F  sharp.  Night, 
C  sharp,  B  flat,  F  sharp. 

February  16th. — Morning,  C  sharp,  B  flat,  F  sharp.  Night, 
F  sharp,  E  flat. 

February  17th.— Morning,  E,  C  sharp,  A.  Night,  D,  B,  G, 
and  so  forth. ' 

Mr.  Hinton  *  regarded  tinnitus  of  a  distinctly  musical  char- 
acter as  a  sign  of  nervous  affection.  One  man  spoken  of  by  him 
was  subject  to  sudden  attacks  of  loss  of  hearing  with  singing 
noise,  and  also  complained  of  dimness  of  vision.  "  Dark  specks  " 
were  found  upon  the  yellow  spot. 


1  American  Journal  of  the  Medical  Sciences,  Vol.  LXVIII.,  p.  378. 
*  The  Questions  of  Aural  Surgery,  p.  286. 


TINNITUS   AURIUM.  349 

Thus  far  I  have  been  speaking  of  subjective  tinnitus,  of 
sounds  of  which  the  patients  give  graphic  descriptions,  as  being 
in  their  head,  but  of  which  the  physician  can  know  nothing  ex- 
cept from  these  narrations.  There  is  also  an  objective  tinnitus 
aurium,  usually  intermittent  in  character  and  of  a  crackling 
nature.  It  is  a  rare  symptom,  and  is  always,  as  far  as  my  ex- 
perience goes,  very  distressing  to  the  patient.  In  one  case, 
where  a  crackling  and  intermittent  sound  could  be  heard  in  the 
ear  both  by  myself  and  the  patient,  the  victim  was  driven  into 
insanity  and  suicide  by  failure  to  get  relief  from  it.  This  kind 
of  noise  in  the  ear  is,  I  believe,  dependent  upon  abnormal  action 
of  the  tensor  tympani,  stapedius,  or  of  the  muscles  of  the  Eus- 
tachian  tube.  I  have  known  the  symptom  to  disappear  when 
the  disease  in  which  it  arose — sub-acute  catarrh — was  relieved, 
but  I  have  never  known  it  to  be  benefited  by  any  treatment 
when  it  occurred  in  conjunction  with  chronic  naso-pharyngeal 
catarrh. 

Ordinary  tinnitus  should  also  be  distinguished  from  a  venous 
murmur  transmitted  from  the  jugular  vein,  which  runs  just 
beneath  the  floor  of  the  cavity  of  the  tympanum,  and  from  the 
pulsating  sound  of  the  internal  carotid  as  it  winds  through  the 
apex  of  the  petrous  bone.  This  variety  of  tinnitus,  is  not  neces- 
sarily connected  with  impairment  of  hearing,  but  is  usually 
dependent  upon  anaemia  or  aneurism. 

The  cause  of  the  common  form  of  subjective  tinnitus  aurium 
has  been  much  discussed,  but  we  are  yet  without  any  exact 
knowledge  as  to  how  it  is  produced.  We  do  know,  however,  in 
what  diseases  it  is  usually  found  as  a  constant  symptom.  It  is 
a  very  common,  almost  universal,  attendant  of  chronic  non- 
suppurative  disease,  and  is  most  distressing  in  the  proliferous 
form,  when  it  forms  the  chief  complaint  of  the  unfortunate  sub- 
jects. It  also  occurs  in  inspissated  cerumen,  in  acute  and  sub- 
acute  catarrh  of  the  middle  ear.  It  is  not  a  prominent  symp- 
tom in  chronic  disease  of  the  labyrinth,  or  at  least  patients  do 
not  speak  of  it  as  being  very  hard  to  bear. 

Reasoning  from  the  standpoint  of  the  diseases  in  which  the 
ordinary  subjective  tinnitus  aurium  is  generally  present,  I  have 
always  considered  it  to  be  a  symptom  indicating  pressure  upon 
the  vessels  of  the  tympanum  and  labyrinth.  Dr.  Theobald ' 
seeks  to  explain  the  nature  of  tinnitus  aurium  by  stating  that  it 
is  due  to  "the  existence  of  vibrations  exerted  in  the  walls  of  the 
blood-vessels  of  the  labyrinth  by  the  friction  attending  the  cir- 
culation of  the  blood."  I  have  found  the  reasoning  of  Field,  of 


Transactions  of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  April,  1875. 


350  CAUSES   OF  TINNITUS   AUKIUM. 

London,  as  to  the  cause  of  tinnitus  very  clear.  He  believes,  as 
I  do,  that  any  impairment  of  the  "pressure  equilibrium"  of  the 
ear  will  be  a  cause  of  tinnitus.  He  has  illustrated  this  thesis  in 
a  very  satisfactory  way.  He  remarks,  abnormal  pressure  of  the 
air  in  the  external  auditory  canal  producing  increased  pressure 
upon  the  endolymph  of  the  cochlea  will  cause  it,  just  as  a  sud- 
den striking  of  the  key-board  of  a  piano  will  set  in  "discordant 
vibration  every  note  that  it  is  capable  of  producing."  Thus  anae- 
mia and  hypersemia,  Mr.  Field  observes,  are  powerful  agents 
in  modifying  pressure  equilibrium.  Overfilled  arteries  and  ar- 
terioles  cause  undue  pressure  on  the  peri-  and  endo-lymph  and 
excite  tinnitus. 

The  tinnitus  from  quinine,  salicylic  acid,  wintergreen,  and  so 
forth,  may  thus  be  explained. 

The  decrease  in  the  pressure  of  the  blood-vessels  in  anaemia  is 
also  called  in  by  Mr.  Field,  to  explain  tinnitus,  and  he  gives  the 
familiar  illustrations  of  chlorotic  young  women,  and  patients 
who  have  suffered  from  great  hemorrhages,  as  examples,  to 
which  may  be  added  the  singing  in  the  ears  experienced  in  syn- 
cope. I  have  long  taught  this  theory  of  increased  pressure,  as 
the  chief  cause  of  subjective  tinnitus  aurium,  and  I  am  very 
glad  to  give  a  new  circulation  to  Field's  more  amplified  and 
better  view  of  the  disturbance  of  pressure  equilibrium,  as  that 
which  causes  an  abnormal  vascular  tension  or  lack  of  tension, 
and  thus  becomes  the  essential  cause  of  tinnitus.1 

Patients  suffering  from  chronic  catarrhal  inflammation  of 
the  middle  ear  usually  speak  of  the  throat  as  troubling  them 
quite  as  much  as  their  ears.  In  many  cases,  however,  they  say 
nothing  whatever  about  the  throat,  and  even  if  asked  about  it, 
they  will  insist  that  it  is  quite  well,  although  they  will  often 
admit  that  they  raise  a  great  deal  of  mucus  in  the  morning,  and 
that  they  have  sore-throat  very  often.  The  greater  number  of 
patients  with  aural  catarrh  complain  greatly  of  the  condition  of 
their  pharynx  and  nostrils,  and,  under  the  stimulus  of  the  ad- 
vertisements and  books  of  charlatans,  have  generally  very  much 
to  say  of  the  catarrh,  although  they  do  not  always  trace  a  con- 
nection between  the  throat  disease  and  that  of  the  ear. 

There  are  very  many  other  symptoms  than  these  which  have 
just  been  enumerated — feelings  of  fulness,  confusion  of  intellect, 
vertigo,  tinnitus,  and  neuralgic  pains — of  which  patients  with 
chronic  catarrh  of  the  middle  ear  often  complain  ;  but  they  are 
not  always  dependent  upon  the  aural  disease,  and  the  examiner 

1  London  Medical  Times  and  Gazette,  June  8,  1878.  Also,  Diseases  of  the  Ear, 
p.  208  et  seq. 


PROLIFEROUS   INFLAMMATION.  351 

may  often  throw  many  of  them  out  of  consideration,  and  bring 
the  patient  back  from  the  long  story  of  headaches,  dyspepsia, 
and  so  forth,  by  asking  whether,  after  all,  if  the  ear  and  throat 
were  well,  they  would  not  consider  themselves  in  good  health, 
when  an  affirmative  answer  is  often  given. 


SUBJECTIVE   SYMPTOMS   OF   PROLIFEROUS  INFLAMMATION. 

If  we  now  turn  to  the  picture  of  the  subjective  symptoms  of 
what  I  term  proliferous  inflammation,  we  shall  find  them  much 
less  positive*  than  those  of  the  catarrhal  form.  Some  of  the 
patients  have  no  subjective  symptoms  at  all,  except  that  of  loss 
of  hearing,  which  is  of  course  an  objective  symptom  as  well. 
They  have  no  sore-throat,  no  increase  of  the  secretion  of  the 
pharynx  or  nostrils.  Others,  again,  complain  of  feelings  of  ful- 
ness in  the  ears,  and  nearly  all  of  tinnitus  aurium.  Indeed,  I 
think  the  tinnitus  is  apt  to  be  more  troublesome  in  the  prolifer- 
ous than  in  the  catarrhal  form.  This  we  should  suppose  a  priori 
to  be  the  case,  because  the  causes  in  the  proliferous  variety  of 
middle-ear  disease  are  constantly  acting,  while  in  the  catarrhal 
variety  the  temporary  removal  of  the  increased  secretion  will 
often  greatly  alleviate  this  symptom,  and  sometimes  completely 
remove  it.  The  origin  of  this  form  of  aural  trouble  cannot  be 
traced  back  to  infantile  earaches,  frequent  coryzas,  or  to  naso- 
pharyngeal  catarrh.  It  is  a  peculiarly  insidious  affection,  one 
which  is  usually  under  full  headway,  and  which  essentially  im- 
pairs the  function  of  hearing  long  before  the  patient  is  aware 
that  he  has  any  affection  of  the  ears.  The  pathology  of  the  dis- 
ease, of  which  an  account  will  be  given  a  little  later  on  in  the 
discussion  of  this  subject,  explains  something  of  this  insidious 
character. 

Catarrhal  and  proliferous  inflammation  may  exist  in  one  and 
the  same  ear,  when  it  will  be  impossible  to  make  a  differential 
diagnosis,  yet  in  the  greater  number  of  cases  the  line  can  be 
drawn  between  the  two  forms. 

Chronic  catarrh  of  the  middle  ear,  as  well  as  proliferous  in- 
flammation may  also  exist  in  connection  with  chronic  disease  of 
the  labyrinth.  The  practitioner  should  not  be  too  ready  to  con- 
clude that  the  predominant  or  chief  affection  in  a  given  case  of 
impairment  of  hearing,  is  to  be  found  only  in  the  middle  ear, 
simply  because  the  patient  has  a  naso  -  pharyngeal  catarrh, 
and  is  hard  of  hearing.  There  are  means  to  distinguish  these 
affections,  of  which  I  shall  speak  fully  before  finishing  this 
subject. 


352  DISEASE   OF   NERVE   AND   MIDDLE   EAR. 

OBJECTIVE   SYMPTOMS  OF   CATARRHAL   INFLAMMATION. 

The  objective  evidences  of  chronic  catarrhal  inflammation  of 
the  middle  ear,  may  be  classified  as  follows  : 

1.  Impairment  of  hearing. 
•  2.  Changes  in  the  membrana  tympani. 

3.  Imperfect  action  and  changes  in  the  structure  of  the  Eus- 
tachian  tube. 

4.  Capability  of  hearing  better  in  a  noise  than  in  a  quiet 
place. 

5.  Better  conduction  of  sounds  through  the  bone  than  through 
the  air. 

6.  Naso-pharyngeal  inflammation. 

If  we  exclude  the  latter,  we  have  also  the  objective  symptoms 
of  chronic  proliferous  inflammation. 

The  Differential  Diagnosis  of  Chronic  Non-suppurative  Inflam- 
mation of  the  Middle  Ear  from  a  Disease  of  the  Labyrinth. 

The  tuning-fork  is  one  of  the  most  useful  means  of  diagnos- 
ticating an  affection  of  the  middle  ear,  from  one  of  the  labyrinth. 
In  the  catarrhal  form  of  disease  its  use  is  not  as  essential  as  in 
the  proliferous,  for  the  good  reason  that  the  subjective  and  ob- 
jective symptoms  together,  form  such  a  decided  picture  that  it 
would  be  hard  to  fall  into  error  as  to  the  seat  or  nature  of  the 
trouble.  But,  in  the  proliferous  form,  both  sets  of  symptoms  are 
often  of  such  a  negative  character,  that  without  the  tuning-fork 
we  are  sometimes  in  doubt  as  to  whether  we  are  dealing  with 
a  peripheric  or  central  disease. 

Starting  from  the  well-established  fact,  that,  if  the  auditory 
canal  of  a  person  having  healthy  ears  be  closed  by  the  finger,  or 
in  any  other  way,  the  sound  made  by  a  vibrating  body  is  heard 
more  distinctly  on  the  side  of  the  head  where  the  ear  is  closed, 
it  has  been  shown  that,  in  most  diseases  of  the  auditory  canal 
and  middle  ear,  such  vibrations  are  more  distinctly  felt  on  the 
affected  side,  or,  if  one  be  diseased,  that  they  are  heard  more 
distinctly  on  the  side  of  the  ear  affected,  and  on  which  the  tick- 
ing of  a  watch  or  the  sound  of  conversation  is  not  as  well  heard. 

The  differential  diagnosis  between  a  chronic  proliferous  in- 
flammation of  the  middle  ear,  and  an  affection  of  the  acoustic 
nerve  is  important  and  often  difficult.  It  is  important,  for  while 
local  treatment  of  a  proliferous  inflammation  of  the  middle  ear 
is  often  beneficial,  such  a  treatment  applied  to  an  affection  of  the 
nerve  is  always  useless  and  generally  harmful.  Certainly  it  adds 


DISEASE    OF   NERVE   AND   MIDDLE   EAR.  353 

to  the  annoyances  of  the  patient.  The  differential  diagnosis  is 
sometimes  difficult,  because  a  secondary  affection  of  the  nerve 
often  exists  in  connection  with  chronic  non-suppurative  inflam- 
mation of  the  middle  ear.  But,  as  I  hope  to  show  in  this  chap- 
ter, and  in  those  upon  "  Diseases  of  the  Internal  Ear,"  some  of 
these  difficulties  have  been  removed,  so  that  we  may  now  more 
readily  make  a  diagnosis  than  was  formerly  possible.  The  tests 
which  were  formerly  exclusively  used  to  differentiate  between 
diseases  of  the  middle  ear  and  of  the  nerve,  and  which  have 
just  been  described,  I  have  of  late,  as  was  said  in  chapter  sec- 
ond, practically  abandoned,  not  because  they  were  not  valu- 
able, but  because  the  test  of  the  aerial  and  bone  conduction  is 
much  more  easy  to  carry  out,  and  is  more  certain.  When  both 
ears  are  diseased,  it  is  often  difficult  for  a  patient  to  say  whether 
or  not  he  hears  a  vibrating  tuning-fork  better  in  one  ear  than  the 
other,  but  the  most  stupid  person  can  easily  determine  whether 
a  vibrating  tuning-fork  is  heard  better  through  the  air,  when 
held  in  front  of  the  meatus,  or  through  the  bone  when  placed 
on  the  mastoid  process.  Now  I  believe  it  is  a  rule  without 
exception,  that  when  the  tuning-fork  C  is  heard  louder  and 
longer  through  the  bones  than  through  the  air,  the  predomi- 
nant disease  is  one  of  the  external  or  middle  ear.  Of  course,  the 
external  ear  may  be  readily  excluded  or  included,  by  ocular  ex- 
amination. There  may,  however,  be  predominant  disease  of  the 
middle  ear,  when  through  any  cause, — wax  in  the  canal,  mucus, 
blood,  serum,  or  pus  in  the  tympanum, — abnormal  pressure  is 
made  upon  the  peri-  and  endo-lymph,  and  yet  the  tuning-fork  be 
heard  better  through  the  air.  When  the  pressure  is  removed, 
if  there  be  remaining  disease  of  the  middle  ear,  the  tuning-fork 
C  will  be  heard  better  through  the  bones.  This  is  beautifully 
shown  in  the  examination  of  boiler-makers,  who  become  hard 
of  hearing  from  their  noisy  occupation,  and  acquire  disease  of 
the  nerve.  They  are  of  course  also  liable  to  disease  of  the  canal, 
such  as  inspissated  cerumen.  Before  the  wax  is  removed  in 
certain  cases,  the  bone  conduction  is  better,  but  on  removing 
this,  the  hearing  power  remains  impaired,  but  the  tuning-fork  is 
heard,  as  it  always  is  heard  in  disease  of  the  nerve,  better  and 
longer  through  the  air.  The  table  showing  the  results  of  exami- 
nation of  boiler-makers  in  the  chapters  011  "Diseases  of  the  In- 
ternal Ear  "  will  show  this. 

The  only  difficulty  then,  in  the  test  with  the  tuning-fork  is 
that  we  cannot  always  tell  on  the  first  examination,  when  the 
tuning-fork  is  heard  better  through  the  air,  whether  this  be  due 
to  pressure  upon  the  labyrinth  from  temporary  causes,  or  to  in- 
trinsic disease  of  the  nerve. 
23 


354  AERIAL   AND   BONE   CONDUCTION. 

By  temporary  causes,  I  mean  an  accumulation  of  wax  in  the 
canal,  or  of  mucus,  pus  or  blood  in  the  tympanum.  These  being 
present,  pressure  may  be  made  upon  the  labyrinth,  and  cause  the 
aerial  conduction  to  be  temporarily  better  than  that  through  the 
bones.  We  cannot,  therefore,  in  some  cases  when  we  find  bet- 
ter aerial  conduction,  determine  at  once,  that  it  may  not  be  due 
to  disease  of  the  canal  or  middle  ear.  We  may  be  obliged  in 
some  such  cases,  to  make  more  than  one  examination  before  we 
come  to  a  positive  conclusion.  With  better  bone  conduction, 
however,  we  have  no  such  difficulty — and  with  constant  use  of 
the  tuning-fork  in  diagnosis,  we  become  more  and  more  confi- 
dent and  exact  in  our  deductions. 

Some  years  since,  I  suggested  a  new  test  with  the  tuning- 
fork,  which  is  stated  in  the  following  proposition.  Generally 
true,  as  I  believe  it  will  be  found,  I  have  abandoned  its  use  also 
for  the  simpler  test  of  the  aerial  and  bone  conduction. 

If,  under  the  same  conditions  of  a  sound  ear  on  one  side,  while 
the  hearing  power  of  the  other  is  impaired,  the  tuning-fork  be 
not  heard  better  in  the  worse  ear,  even  if  the  meatus  be  stopped 
by  the  finger  or  the  like,  there  is  disease  of  the  labyrinth,  the 
acoustic  nerve  or  brain. 

I  employed  the  older  tests,  until  constant  examinations  have 
convinced  me,  that  the  one  as  to  the  aerial  and  bone  conduction 
is  the  most  reliable  and  easiest  to  conduct  of  all  those,  that  have 
resulted  from  Miiller's  first  experiments. 

I  now  use  the  tuning-fork  simply  to  determine  which  is  bet- 
ter, the  aerial  or  the  bone  conduction.  At  my  clinics,  where  I 
have  a  class  of  practitioners,  I  have  invariably  found  that  it  is 
considered  a  simple  and  adequate  test,  by  those  who  have  seen 
it  employed  upon  almost  all  kinds  of  patients.  It  is  indeed  a 
very  simple  thing  to  determine  whether  the  vibrations  of  a  tun- 
ing-fork are  heard  better  through  the  air,  or  through  the  bones, 
and  this  is  the  gist  of  the  test.  In  some  cases  it  is  well  to  also 
test  the  time  during  which  the  fork  is  heard.  A  simple  way  of 
doing  this  is  to  place  it  upon  the  bones,  after  the  patient  says  it 
is  no  longer  heard  through  the  air,  or  vice  versa.  In  many  in- 
stances, however,  a  stop-watch  and  a  test  of  the  duration  in  each 
position,  are  necessary  to  an  accurate  idea  as  to  the  relative  in- 
tensity of  aerial  and  bone  conduction. 

After  having,  in  the  doubtful  cases  of  the  proliferous  variety, 
settled  the  fact  as  to  whether  we  have  an  affection  of  the  middle 
ear  or  of  the  labyrinth,  the  ticking  of  the  watch  and  ordinary 
conversation  become  the  natural  tests  as  to  the  impairment  of 
hearing. 

The  watch  is  an  inadequate  test,  for  the  reason  that  has 


POWER  OF   HEARING  WATCH   AND   SPEECH.  355 

already  been  mentioned  in  the  introductory  chapter,  that  is, 
that  some  persons  can  hear  a  watch  quite  a  number  of  inches 
from  the  ear,  while  they  hear  conversation  very  badly.  Lucae 
explains  this  fact  by  saying,  that  speech  is  made  up  of  an  ex- 
tremely complicated  system  of  tones,  and  sounds  of  most  differ- 
ent tone-heights,  while  the  tick  of  a  watch  is  made  up  of  a  class 
of  very  high  tones  which  are  usually  better  heard  than  low  ones. 
But,  there  are  cases  where  speech  is  heard  much  better  than  the 
tick  of  a  watch.  Careful  observation  of  the  lips  of  the  speaker, 
by  the  person  whose  hearing  is  defective,  may  have  something 
to  do  with  explaining  this  class  of  cases.  Excluding  these,  how- 
ever, I  have  become  convinced  that  there  is  disease  of  the  acous- 
tic nerve,  when  conversation  is  heard  relatively  better  than  the 
tick  of  a  watch.  I  have  come  to  this  conclusion,  because  I  have 
almost  invariably  found  this  symptom  in  connection  with  others 
that  indicate  an  affection  of  the  nerve. 

In  commenting  upon  Lucae's  explanation  of  the  occasional 
disproportion,  between  the  power  of  hearing  the  watch  and  con- 
versation, Politzer  remarks  that  he  believes  it  to  be  due  to  the 
fact  that  in  anchylosis  of  the  stapes,  the  membrane  of  the  fen- 
estra  rotunda  often  remains  .normal.  If  this  be  not  thickened, 
he  goes  on  to  say,  that  simple  tones  and  noises  may  be  trans- 
mitted without  difficulty  through  the  air  of  the  tympanum  to 
the  membrane  of  the  fenestra  rotunda,  while  speech  can  only 
be  perfectly  transmitted  through  the  ossicles.  "  The  greater  the 
impediment  to  the  conduction  of  sound  through  the  ossicles,  the 
greater  is  the  impairment  of  hearing  for  speech."  '  This  expla- 
nation is  perfectly  consistent  with  my  experience,  for  I  have 
found  an  adhesive  process  in  the  tympanum  more  destructive  to 
the  hearing  power  for  speech,  that  is  for  ordinary  conversation 
than  a  disease  of  the  labyrinth.  Deaf  mutes,  who  are  usually 
deaf  from  adhesive  inflammation  of  the  middle  ear.  are  striking 
examples  of  persons  deaf  to  speech,  although  they  may  hear 
sounds  and  noises  through  the  bones. 

BETTER  HEARING  IN  A  NOISE. 

Persons  affected  with  disease  of  the  middle  ear,  uncomplicated 
by  secondary  disease  of  the  labyrinth,  hear  better  in  a  noise  than 
they  do  in  a  quiet  place.  This  is  true  of  acute,  sub-acute,  and 
chronic  disease.  But  it  has  only  been  especially  commented 
upon  when  occurring  in  chronic  non-suppurative  cases.  Con- 
sequently it  has  often  been  mistakenly  assumed,  that  it  is  always 


Lehrbuch,  p.  394. 


856  BETTER   HEARING   IN   A  NOISE. 

a  very  unfavorable  symptom.  It  is  not  necessarily  so,  but  inas- 
much as  it  is  chiefly  observed  in  cases  that  are  actually  incur- 
able, it  is  not  at  all  strange  that  it  has  been  so  considered.  I 
believe  that  important  deductions  can  already  be  made  as  to 
the  situation  of  the  nature  of  the  lesion  that  causes  the  impair- 
ment of  hearing  in  a  given  case,  from  this  symptom,  and  I  also 
hope  that  from  a  right  interpretation  of  it,  may  yet  come  an 
invention  to  improve  the  hearing  power  of  a  large  class  of  per- 
sons. For  these  reasons,  I  shall  be  quite  full  in  my  account  of 
this  symptom. 

In  the  collected  works  of  Doctor  of  Medicine  Thomas  Willis, 
published  in  Amsterdam,  a  little  more  than  two  hundred  years 
ago.  in  a  chapter  upon  the  sense  of  hearing,  and  in  a  paragraph 
relating  to  deafness  caused  by  relaxation  of  the  membrana  tym- 
pani,  there  is  ah  account  of  a  somewhat  famous  woman,  who 
could  only  hear  the  voice  of  her  husband  when  a  servant  was 
beating  a  drum  in  the  same  room.1 

Although  this  passage  is  often  alluded  to,  it  is  seldom  quoted. 
No  apology  will,  I  think,  be  required  for  a  translation  of  it. 

"Although  hearing  is  very  little  produced  by  the  membrana 
tympani  as  compared  with  the  proper  organ  of  the  sense,  yet  it 
so  far  depends  upon  it,  that  deprivation  or  diminution  of  that 
sense  not  infrequently  proceeds  from  its  injury  or  impeded  action. 
Indeed,  a  certain  kind  of  deafness  occurs,  in  which,  although  the 
patients  seem  completely  to  lack  the  sense  of  hearing,  yet  so 
long  as  a  great  din,  such  as  that  of  bombardments,  or  of  chimes 
of  bells,  or  of  drums,  resounds  about  their  ears,  they  take  in 
distinctly  the  conversation  of  those  about  them,  and  answer 
questions  intelligently,  but,  upon  the  ceasing  of  such  tremendous 
uproar,  they  immediately  become  deaf  again.  I  once  had  it  from 
a  trustworthy  man,  that  he  had  been  acquainted  with  a  woman, 

1  Archives  of  Otology,  vol.  xii. ,  No.  2,  June,  1883.  The  original  reads  as  follows : 
Quanquam  aMitus  a  tympana,  velut  proprio  sen«ionin  organo,  minime  peragitur, 
tamen  iste  in  tantum  ab  hoe  dependet,  ut  non  raro  d  tympani  actions  Icesa,  out  impedita 
sensus  iUivs  primtio,  aut  diminutio  procedat.  Enimtero  surditatis  specie*  qucedam  occur- 
rit,  in  qua  licet  affecti  au  'itus  sensu  penitm  carere  rideantur,  quam-diu  tamen  ingens 
fragor,  uti  bombardarum,  campanarum,  aut  tympani  bellici,  prope  aures  circumstrepit, 
adstanlium  cottoquia  distincte  capiunt,  et  interrogatis  apte  respondent,  cessante  vero  im- 
mani  isto  strepitu,  denuo  statim  obsurdescunt.  Accept  olim  d  Tiro  fide  digno,  se  muli- 
erem  qua  licet  surda  fuerat,  quousque  tamen  intra  conclave  tympanum  pulsaretur,  verba 
quaevis  clttre  audiebat;  quare  maritus  ejus  Tympanistam  pro  ferco  domestics  conducebat, 
ut  ulius  ope,  coUoquia  interdum  cum  uxore  sua  haberet.  Etiam  de  alio  Surdastro  mild 
narratum  est,  qui  prope  campanile  degens,  quoties  una  plures  campana  resonarent,  vocem 
quamris,  facile  audire,  et  non  alias  potuit.  Proculdubio  horum  ratio  erat,  quod  tym- 
panum in  se  continue  relaxatum,  soni  vehementioris  impulsu  ad  debitam  tetisitatem,  quo 
munere  suo  aliquatenus  de  fungi  potuerit,  cogeretur. 


BETTER   HEARING   IN  A   NOISE.  357 

who,  although  she  was  deaf,  would,  nevertheless,  distinctly  hear 
whatever  was  said  so  long  as  a  drum  was  beaten  within  the  room, 
and  consequent^  her  husband  employed  a  drummer  as  a  house- 
hold servant,  in  order  that  by  his  aid  he  might  occasionally  hold 
conversations  with  his  wife.  I  have  also  been  told  of  another 
deaf  person,  living  near  a  bell-tower,  who  could  easily  hear  any 
voice  whenever  the  bells  were  pealing — but  not  otherwise.  Doubt- 
less the  reason  of  these  things  is,  that  the  membrana  tympani, 
habitually  relaxed  when  left  to  itself,  was  forced  by  the  shock 
of  a  sound  much  more  intense  than  usual,  to  a  state  of  tension 
sufficient  to  enable  it  to  perform  its  function  in  some  degree." ' 

In  the  two  centuries  that  have  followed  the  narration  of 
Willis's  observations,  the  symptom  of  hearing  better  in  a  noise, 
has  not  only  been  given  the  name  of  the  author,  and  is  known 
in  our  time  as  Paracusis  Willisiana,  but  the  facts  as  stated  by 
the  author,  have  in  turn  been  denied  and  affirmed,  and  while 
many  have  admitted  the  truth  of  the  observations,  and  have 
conceded  that  there  are  some  persons  with  impaired  hearing 
who  hear  better  in  a  noise,  Willis's  explanation  of  the  phenom- 
enon has  been  rejected  by  them.  The  writers  on  aural  medi- 
cine who  allude  to  it  at  all,  are  by  no  means  agreed  upon  the 
facts  nor  upon  their  explanation.  Wilde 2  admits  the  credibility 
of  Willis's  cases,  and  argues  against  the  notion  of  Kramer,  that 
the  auditory  nerve  became  so  excited  by  these  loud  sounds  as  to 
be  able  to  do  its  work  better.  Wilde  explains  the  phenomenon 
by  reference  to  the  state  of  the  membrana  tympani,  and  says 
that  it  is  remarkable  that  it  does  not  occur  in  cases  where  that 
structure  has  been  in  whole  or  in  part  removed.  Later  on,  I 
shall  show  that  Wilde  was  in  error  in  thinking  that  it  could  not 
occur  when  there  was  a  hole  in  the  drum-head. 

Troltsch3  says  :  "These  statements  (as  to  hearing  better  in  a 
noise)  are  founded,  as  a  rule,  upon  a  want  of  exact  observation, 
as  well  as  upon  self-deception."  He  then  relates  one  of  Willis's 
cases,  and  also  one  reported  by  an  author  named  Fielitz.  The 
latter  was  that  of  a  deaf  son  of  a  shoemaker,  who  could  only 
hear  conversation  in  the  room,  when  he  stood  near  his  father 
and  the  latter  pounded  sole  leather  upon  a  large  stone.  This 
same  boy,  heard  well  in  a  mill  when  it  was  in  action. 

I  cannot  agree  with  Troltsch,  in  his  idea  that  the  symptom  of 
hearing  better  in  a  noise  is  not  a  common  one.  As  I  have  said 
on  several  occasions,  my  own  experience  has  proven  that  it  is  a 


1  Opera  Omnia,  Amstelsedamia.,  apud  Henricum  Wetstenium.     Pars  physiologica, 
Cap.  xiv. ,  p.  09  *  Aural  Surgery,  English  edition,  p.  289. 

3  Troltsch :   Lehrbucli,  Sechste  Ausgabe,  p.  253,  passim. 


BETTER  HEARING   IN   A   NOISE. 

very  frequent  one.  Rau, '  like  Kramer,  believed  that  better  hear- 
ing in  a  noise  depends  upon  excitement  of  a  torpid  acoustic  nerve. 
In  somewhat  poetic  style,  he  says  :  "If  the  auditory  nerve  be 
awakened  from  its  slumber  by  loud  talking,  the  patient  will  mo- 
mentarily hear  even  words  spoken  in  a  low  tone  very  well.  This 
sometimes  goes  to  such  an  extent,  that  the  hearing  is  temporarily 
restored  to  a  considerable  degree  by  a  loud  and  regular  sound, 
for  example,  during  the  pealing  of  bells,  drumming,  a  ride  in  a 
rattling  wagon,  or  the  like."  Burnett,4  of  our  own  country,  is  pos- 
itive that  the  symptom  is  a  real  one,  but  confines  it  to  the  later 
stages  of  chronic  aural  catarrh,  "  when  the  condition  of  the  tym- 
panum has  become  dry  or  sclerotic,  or  when  the  thickening  of 
the  mucous  membrane  has  become  great  in  the  moist  form." 

Dr.  E.  E.  Holt '  doubts  if,  in  any  case  the  hearing-power  is  im- 
proved by  noise,  and  he  states  that,  so  far  as  he  is  aware,  no  one 
has  "ever  made  a  careful  investigation  to  ascertain  whether  the 
claim  of  such  persons  was  a  real  one  or  not." 

In  the  first  edition  of  this  book,  and  in  all  the  subsequent  edi- 
tions, I  related  from  my  personal  experience  the  case  of  a  mail 
agent,  on  one  of  our  railways,  who,  although  very  hard  of  hear- 
ing in  a  quiet  place,  could  hear  very  well  in  his  car  amid  the 
noise  of  a  train.  I  have  had  frequent  opportunities  to  study  this 
case,  and  there  is  no  question  as  to  the  facts.  No  person  who 
did  not  know  of  this  gentleman's  infirmity,  would  ever  suspect 
him  of  impaired  hearing  while  conversing  in  the  din  of  a  rapidly 
going  train  of  railway  carriages.  But  the  instant  he  reached  a 
quiet  place,  it  was  with  the  greatest  difficulty,  that  he  could  hear 
loud  conversation  specially  addressed  to  him. 

Politzer  has  no  doubts  as  to  the  existence  of  these  cases,  and 
confirms  what  was  stated  by  me  years  ago,  "that  the  patients 
can  understand  speech  during  such  noises  much  easier,  and  at 
a  much  greater  distance,  than  people  with  normal  hearing."* 
Politzer,  however,  states  that  he  has  observed  this  symptom 
"  almost  exclusively  in  the  incurable  forms  of  affections  of  the 
middle  ear." 

I  have  known  of  two  cases  where  this  symptom  occurred,  in 
patients  who  regained  their  hearing  perfectly.  While  the  symp- 
tom frequently  accompanies  incurable  disease  of  the  middle  ear, 
I  believe  it  is  a  very  frequent  symptom  in  sub-acute  cases,  when 
both  ears  are  affected.  Of  course,  it  would  not  be  observed  in 
disease  of  one  ear  only.  I  also  have  two  cases  under  observation 
in  which  the  drum-heads  are  entirely,  or  nearly  removed,  and  yet 
these  patients  hear  well  in  a  noise.  One  of  these.  I  published  in 

1  Lehrbuch,  p.  292.  *  Treatise  on  the  Ear,  p.  386. 

3  Transactions  of  American  Otological  Society,  1882.  4  Lehrbuch,  p.  233. 


BETTER   HEARING   IN   A    NOISE.  359 

the  fourth  edition  of  this  book.  While  the  occurrence  of  the  symp- 
tom in  sub-acute  cases  disposes  of  the  notion  that  hearing  better 
in  a  noise  implies  an  incurable  disease,  the  fact  that  it  also  may 
exist  when  the  membrana  tympani  is  gone,  shows  that  Willis's 
explanation  of  the  phenomenon  is  not  exclusively,  if  at  all,  cor- 
rect. I  have  never  yet  seen  the  symptom  except  in  disease  of  the 
middle  ear.  I  believe  it  never  occurs  except  in  cases  where  the 
nerve  is  sound.  I  have  looked  over  my  cases  with  great  care  as  to 
this  point,  and  I  have  yet  to  see  a  patient  who  had,  as  I  supposed, 
disease  of  the  acoustic  nerve,  and  who  yet  heard  better  in  a  noise. 
If  this  be  true,  the  theory  of  an  extraordinary  excitement  of  the 
nervous  apparatus,  as  a  cause  of  the  phenomenon,  must  be  re- 
jected. Buck  and  Politzer,  explain  the  symptom  by  a  reference 
to  some  effect  upon  the  ossicula  auditus,  made  by  the  great  din. l 
This  is  the  only  theory,  incomplete  as  it  is,  which  fulfils  the  con- 
ditions made -by  such  cases  as  those  just  mentioned,  where,  al- 
though the  membranse  tympani  were  gone,  the  ossicula  were  in- 
tact. How  the  ossicles  aye  affected  is  a  problem  yet  to  be  solved, 
but  when  it  is  solved,  it  will  be  possible  to  invent  an  instrument 
to  enable  those  deaf  from  disease  of  the  middle  ear,  to  hear  con- 
versation not  only  in  a  noise,  but  in  the  quiet  of  an  ordinary  room. 
This  latter  will,  certainly,  not  be  a  task  beyond  the  capabilities 
of  a  physicist  of  the  nineteenth  century.  These  cases  are  not 
at  all  rare.  They  are  very  common.  The  proof  is  overwhelm- 
ing that  a  large  class  of  persons  with  impairment  of  hearing  not 
only  hear  better,  but  hear  perfectly  well,  in  noisy  places. 

The  statement,  that  these  cases  rest  upon  inexact  observa- 
tions, will  soon  be  disproven  by  a  ride  of  a  few  miles  in  a  rail- 
way carriage  or  in  a  clattering  wagon,  with  a  person  deaf  from 
disease  of  the  middle  ear,  to  ordinary  conversation  in  a  quiet  place. 
Examinations  of  boiler-makers,  or  of  those  who  suffer  from  af- 
fections of  the  acoustic  nerve,  will,  however,  be  disappointing 
unless  they  are  carefully  analyzed,  and  will  lead,  as  in  Dr.  Holt's 
paper,  from  which  I  have  already  quoted,  to  a  doubt  in  the  mind 
of  the  observer  as  to  the  reality  of  the  symptom.  I  now  quote 
one  of  the  cases  in  which  the  hearing  was  better  in  a  noise,  and 
which  was  one  of  sub-acute  catarrh  of  the  middle  ears,  from  which 
the  subject  fully  recovered  under  my  observation.  The  writer  of 
his  own  case  is  now  a  practising  physician  in  this  city.  At  the 
time  of  the  occurrence  of  the  disease  he  was  a  boy  in  school, 
and  I  reported  his  case,  except  as  to  the  symptom  now  under  dis- 
cussion, in  the  American  Journal  of  the  Medical  Sciences 2  and  in 
the  first  edition  of  this  book.  Dr.  B—  -  writes  to  me  as  follows  : 

1  Medical  Record,  Julj  5,  1875.  2  Vol.  Hi. ,  p.  G4. 


360  BETTER  HEARING   IN  A   NOISE. 

With  regard  to  the  disputed  fact  of  many  deaf  persons  hearing  conversation 
better  in  noisy  places,  I  wish  to  give  in  brief  my  experience.  For  several  years 
previous  to  my  sixteenth,  I  had  been  much  troubled  with  varying  degrees  of  deaf- 
ness, due,  as  I  then  heard  and  now  understand,  to  acute  catarrh  of  the  middle  ear, 
complicating  general  pharyngeal  catarrh.  At  school  I  was  at  a  great  disadvan- 
tage, suffering  at  times  great  embarrassment  on  account  of  my  limited  hearing. 
Living  far  up-town,  I  was  in  the  habit  of  being  driven  home  or  to  the  doctor's 
by  my  mother.  When  surrounded  by  the  noise  of  wheels  and  glass,  I  invariably 
had  occasion  to  request  a  moderation  of  her  voice  ;  and  she  not  infrequently  made 
the  remark  :  "  How  well  you  hear  in  the  carriage  !  "  Furthermore,  on  several 
occasions,  my  parents  were  surprised  to  find  that  they  could  not  safely  carry  on  a 
confidential  conversation  requiring  only  sound  enough  to  suffice  their  own  hear- 
ing powers,  while  in  a  quiet  room  their  talk  would  have  been  unintelligible. 

This  is  only  an  echo  of  the  experience  of  many  deaf  people  I  have  ques- 
tioned on  the  subject. 

The  other  case  was  that  of  a  student,  of  seventeen  years  of  age, 
and  is  so  similar  to  the  one  just  given,  that  I  simply  allude  to  it. 
As  I  have  already  intimated,  the  power  of  hearing  better  in  a  noise 
is  a  different  subject  from  that  of  the  effect  of  certain  noisy  occu- 
pations upon  the  ear.  Patients  like  my  friend,  the  mail  agent, 
may  travel  for  years  in  the  din  of  a  train,  and  always  find  their 
hearing  improved  and  not  decreased,  so  long  as  it  depends  upon 
disease  of  the  middle  ear.  Neither  do  I  know  of  any  cases  of  deaf- 
ness that  have  been  caused  by  such  occupations.  But  although 
there  is  a  class  of  patients  who  have  been  made  deaf  by  noise, 
often  confounded  with  those  whose  impairment  of  hearing  has 
resulted  from  catarrh,  they  should  be  entirely  disassociated  from 
them.  Boiler-makers,  and  those  who  become  deaf  from  an  expos- 
ure to  the  continuous  shock  of  loud  sounds,  suffer  a  lesion  of  the 
acoustic  nerve.  These  patients  do  not  hear  better  in  a  noise,  but 
they  have  a  source  of  relief  in  quiet  places,  and,  like  ordinary 
people,  they  hear  better  away  from  the  din  that  is  such  a  comfort 
to  a  person  deaf  from  many  forms  of  disease  of  the  middle  ear. 

I  must  confess  to  have  assisted  in  the  creation  of  confusion 
in  our  ideas  as  to  hearing  better  in  a  noise,  and  the  effects  of 
noise  upon  the  ear.  In  1874,  in  one  of  the  editions  of  this  work, 
I  gave  the  results  of  my  examinations  of  a  certain  number  of 
boiler-makers,  and  I  incidentally  assumed  that  they  heard  better 
in  the  noise  of  their  occupations.  When  the  paper  by  Dr.  Holt, 
to  which  I  have  referred,  appeared,  I  found  that  he  denied  the 
correctness  of  my  main  conclusions  ;  that  is,  that  the  impair- 
ment of  hearing  in  boiler-makers  is  generally  a  result  of  a  lesion 
of  some  part  of  the  labyrinth,  and  that,  besides  his  doubt  that 
any  deaf  person,  much  less  boiler-makers,  ever  heard  better  in 
a  noise,  he  was  inclined  to  attribute  their  impairment  of  hearing 
to  a  disease  of  the  middle  ear.  I  then  made  a  new  series  of  ex- 


BETTER  HEARING   IN   A   NOISE.  361 

aminations  upon  boiler-makers,  assisted  by  Dr.  J.  B.  Emerson. 
As  a  result  of  these  recent  investigations,  which  were  under- 
taken with  the  much  better  means  of  a  differential  diagnosis 
between  diseases  of  the  middle  and  internal  ear,  now  at  our 
command,  I  find  that  I  cannot  agree  with  Dr.  Holt's  conclu- 
sions, except  in  one  particular,  and  that  is  the  one  just  men- 
tioned, i.e.,  that  boiler-makers  do  not  hear  better  in  a  noise. 
This  incidental  statement  made  by  me,  I  now  find  to  be  entirely 
incorrect.  But  that  boiler-makers  do  suffer  from  a  lesion  of  the 
internal  ear,  and  not  of  the  middle  ear,  in  so  far  as  they  have  a 
peculiar  affection  from  their  occupation,  I  do  not  think  admits 
of  a  doubt.  The  very  fact  that  they  do  not  hear  better  in  a  noise 
is  an  incidental  proof  that  they  suffer  from  a  lesion  of  the  laby- 
rinth. Boiler-makers,  like  men  in  other  occupations,  often  have 
impacted  cerumen,  and  occasionally  catarrh  of  the  middle  ear, 
but  the  disease  caused  by  their  occupation,  "boiler-makers' 
deafness,"  in  my  opinion,  is  easily  shown  to  be  a  disease  of  the 
labyrinth.  Other  occupations  of  a  similar  nature,  that  is,  occu- 
pations amid  continuous  concussions,  undoubtedly  cause  the 
same  lesion.  A  recent  visit  to  an  establishment  where  two' 
engineers  were  employed  for  the  production  of  electric  light, 
showed  me  that  they  had  become  somewhat  hard  of  hearing, 
since  they  had  been  engaged  in  an  occupation  exposing  them  to 
the  sound  of  regular  concussions  from  the  striking  of  metallic 
plates  together. 

The  confusion  which  I  assisted  in  producing  upon  the  sub- 
ject was  not,  however,  as  regards  the  seat  or  cause  of  the  aural 
lesion,  but  as  regards  the  ability  of  these  workmen  to  hear  better 
in  the  din  in  which  they  labor.  It  will  perhaps  be  remembered 
that  it  has  just  been  stated  that  those  who  hear  better  in  a  noise 
always  suffered  from  some  form  of  disease  of  the  middle  ear. 
When  some  years  of  observation  had  convinced  me  of  the  uni- 
formity of  this  rule,  I  was  puzzled  to  account  for  my  cases  of 
so-called  boiler-makers'  deafness,  which,  in  my  paper  upon  this 
subject,  I  had  assumed  were  also  improved  by  being  in  a  noise. 
I  had  said  :  "It  will  be  observed  that  the  subjects  of  it  (boiler- 
makers'  deafness)  hear  very  well  in  the  tremendous  din  of  a 
boiler-shop,  while  they  are  quite  deaf  in  an  ordinarily  quiet 
place."  This  remark,  I  am  constrained  to  say,  although  in 
the  other  editions  of  this  book,  is  strikingly  incorrect.  Boiler- 
makers, as  we  should  naturally  believe,  are  no  exception  to  the 
rule,  that  those  who  have  disease  of  the  nerve  hear  worse  in  a 
noise.  Boiler-makers  hear  so  badly  in  their  shops  that  they 


1  Treatise  on  the  Ear,  third  edition,  p.  510. 


362  BETTER   HEARING   IN   A   NOISE. 

have  a  language  of  signs  that  is  quite  elaborate,  called  a  "boiler- 
makers'  language."  They  hear  no  better  in  a  noise  than  do 
people  with  sound  ears  ;  on  the  contrary,  they  hear  better  in  a 
quiet  place. 

If,  however,  a  person  deaf  from  disease  of  the  middle  ear, 
who  hears  better  in  the  noise  of  a  railway  train,  enters  a  boiler- 
shop,  that  person  will  hear  better  than  the  boiler-makers,  or 
than  persons  with  sound  ears. 

It  is  only  very  recently  that  I  have  been  able  to  send  a  pa- 
tient suffering  from  chronic  disease  of  the  middle  ear,  who  heard 
well  in  a  railway  carriage,  to  a  boiler-shop.  I  had  predicted, 
that  although  boiler-makers  with  disease  of  the  acoustic  nerves 
and  persons  with  sound  ears,  hear  very  badly  in  the  dreadful 
din,  such  a  patient  would  hear  well  in  such  a  place. 

The  patient  whom  I  sent  is  a  lady  of  about  thirty  years  of 
age,  who  has  had  chronic  disease  of  the  middle  ears,  of  the  pro- 
liferous form,  for  many  years.  She  cannot  hear  the  watch  at 
all,  and  conversation  only  when  directed  into  the  ear,  and  then 
with  difficulty.  In  the  cars  she  hears  very  well.  She  only  hears 
the  tuning-fork  by  bone-conduction.  Her  account  of  the  experi- 
ment is  as  follows  : 

"  I  went  with  my  husband  (he  has  excellent  hearing)  this 
afternoon  to  the  boiler-shops  of  the  Dickson  Co.  (Scranton,  Pa.), 
where  the  noise  is  perfectly  deafening.  I  could  distinctly  hear 
what  my  husband  said,  although  he  purposely  spoke  in  a  low 
tone,  while  he  could  not  hear  a  word  I  said,  unless  I  put  my 
mouth  to  his  ear  and  screamed.  I  think,  perhaps,  cars  and 
boiler-shops  are  the  places  for  me  to  live."  In  a  subsequent  note 
she  informs  me  that  she  could  not  hear  the  watch  tick,  although 
she  hears  conversation  so  easily. 

In  this  case  it  will  be  noted  that  the  improvement  does  not 
depend  upon  the  loud  tone  of  the  speaker. 

The  fact  that  most  patients  suffering  from  disease  of  the 
middle  ear  hear  better  in  a  noise,  especially  that  of  a  railway 
car,  I  find  as  a  result  of  a  series  of  examinations  extending  over 
many  years,  and  embracing  several  hundreds  of  cases.  Wher- 
ever this  symptom  is  not  present,  I  have  found  that  either  the 
disease  was  primarily  or  secondarily  one  of  the  labyrinth  or 
acoustic  nerve. 

I  have  gone  with  such  patients  to  a  train  in  motion,  and  I 
have  always  found  their  statements  correct.  From  hearing  a 
voice  with  difficulty  directly  in  the  ear,  they  have  been  enabled 
to  hear  it  twenty  feet,  that  is  to  say  to  hear  conversation  at  that 
distance  and  with  ease.  In  my  experience  they  do  not  always 
hear  a  watch  tick  farther,  but  most  of  these  marked  subjects 


BETTER   HEARING  IN   A   NOISE.  368 

hear  a  watch  a  very  short  distance,  if  at  all,  in  a  quiet  place. 
There  is,  I  think  with  Politzer,  sometimes  an  improvement  in 
this  respect  also. 

I  have  also  made  many  tests  in  my  clinic,  in  the  following 
manner,  for  the  purpose  of  demonstrating  this  phenomenon  to 
my  class.  I  have  first  tested  the  perception  of  sound  by  aerial 
and  by  bone  conduction.  I  have  then  made  the  room  as  quiet 
as  was  possible,  and  tested  the  capability  of  the  patient  for  hear- 
ing conversation.  Then  the  room  has  been  made  as  noisy  as 
could  readily  be  done  by  moving  chairs  on  the  tiled  floor,  rap- 
ping on  walls  and  tables,  and  so  forth,  and  I  have  again  tested 
the  hearing.  Invariably  have  I  found,  that  when  the  tuning- 
fork  was  perceived  on  both  sides  better  through  the  bones,  that 
the  power  of  hearing  was  better  in  a  noise,  and  also  that  the  re- 
verse was  true.  The  result  may  be  formulated  as  follows  : 

Bone-conduction  better. 
Better  hearing  in  a  noise. 
Disease  of  middle  ear. 

Aerial  conduction  better. 
Worse  hearing  in  a  noise. 

Disease  of  acoustic  nerve,   either  primary  or 
secondary. 

This  symptom  would  often  be  found  in  acute  disease  of  both 
r>ides  did  such  diseases  last  long  enough  to  admit  of  proper  tests. 
To  say  that  the  whole  explanation  is  to  be  found  in  the  fact  that 
the  voice  is  raised  when  in  a  noise,  is  to  forget  that  even  in  a 
quiet  place,  with  just  such  an  elevation  of  the  voice,  these  pa- 
tients do  not  hear  as  well  as  they  do  in  the  noise.  Besides,  the 
elevation  in  the  voice  is  usually  only  slight,  and  sometimes  there 
is  none  at  all. 

I  have  yet  to  find  a  case  where  a  mistake  was  made  in  a  de- 
liberate statement  by  a  patient,  that  conversation  was  heard 
better  in  a  noise.  When  the  symptom  does  occur,  it  is  so 
marked  that  no  mistake  can  be  made.  When  a  patient  does 
not  know  whether  he  does  or  does  not  hear  better  in  a  noise,  we 
may  assume  that  he  does  not,  and  when  he  does  not,  the  case 
will,  I  think,  always  be  found  to  be  one  in  which  the  nerve  is 
somewhat  involved. 

From  all  the  observations  I  have  been  able  to  make  upon 
this  subject,  I  think  I  am  justified  in  drawing  the  following 
conclusions  : 

1.  There  is  a  large  class  of  people  suffering  from  impairment 


364  CHANGES   IN   MEMBRANA   TYMPANI. 

of  hearing  in  quiet  places,  who  hear  very  acutely  and  with 
comfort  amid  a  great  din  or  noise. 

2.  The  disease  causing  the  impairment  of  hearing  thus  re- 
lieved is  situated  in  the  middle  ear.     It  is  usually  observed  in 
the  chronic,  non-suppurative  form  of  disease  of  the  middle  ear, 
but  it  may  also  be  found  in  acute  or  sub-acute  catarrh  of  this 
part,  as  well  as  in  a  chronic  suppurative  process  with  loss  of  the 
whole  or  a  part  of  the  membrana  tympani. 

3.  The  proximate  cause  of  this  phenomenon  is  not  as  yet  posi- 
tively known.     It  is  probably  to  be  found  in  some  change  in  the 
action  of  the  articulations  of  the  ossicula  auditus. 

If  a  physicist  can  give  us  an  instrument  which,  being  placed 
in  the  auditory  canal,  will  produce  sound  enough  to  act  upon 
the  ossicles,  as  does  a  great  noise  in  a  room,  or  the  noise  of  a 
railway  train,  we  shall  have  found  magnifying  lenses  for  the 
deaf. 

CHANGES  IN  THE  MEMBRANA  TYMPANI. 

I  do  not  regard  the  appearance  of  the  drum-head  as  posi- 
tively indicative  of  aural  disease.  In  some  few  cases,  we  find 
the  membrane  in  what  may  fairly  be  said  to  be  a  normal  con- 
dition in  appearance,  and  yet  we  may  have  a  very  great  im- 
pairment of  hearing,  which  the  other  objective  symptoms  as 
well  as  the  tuning-fork,  show  to  depend  upon  disease  of  the 
middle  ear.  These  cases  are  not  common,  and  then,  if  the 
loss  of  hearing  is  great,  we  may  conclude  that  the  alterations 
in  structure  are  chiefly  upon  the  inner  or  labyrinthine  wall 
of  the  cavity  of  the  tympanum.  I  think,  however,  that  we 
very  rarely  find  an  absolute  sinking  inward  of  the  membrane, 
unless  attended  by  some  impairment  of  hearing.  A  sunken 
drum-head,  that  is,  one  in  which  the  head  of  the  malleus  stands 
out  like  a  miniature  button,  while  the  whole  membrane  seems 
collapsed  and  sunken,  is  pretty  fair  evidence  of  the  existence 
of  adhesions  in  the  cavity  of  the  tympanum,  and  of  impairment 
of  hearing. 

The  first  question  in  studying  the  membrana  tympani  is, 
very  naturally,  what  is  the  appearance  of  a  normal  one  ?  The 
introduction  of  Troltsch's  method  of  examining  the  membrana 
tympani,  has  done  more  than  anything  else  to  stimulate  the 
study  of  its  character.  The  ordinary  anatomical  text-books 
give  no  true  idea  of  this  beautiful  and  important  part.  Such 
authorities  on  aural  disease  as  Kramer,  Wilde,  and  Toynbee, 
give  descriptions  of  it  that  are  far  from  exact.  To  Troltsch 
and  Politzer  we  are  indebted  for  such  perfect  descriptions,  that 


CHANGES   IN   MEMBRANA   TYMPANI.  365 

we  now  have  a  complete  guide  to  the  changes  that  may  occur 
upon  it. 

In  order  to  determine  what  may  fairly  be  considered  a  nor- 
mal membrana  tympani,  I  have  examined  a  number  of  what 
may  be  considered  healthy  ears.  The  persons  whose  ears  were 
thus  examined  were  not  aware  that  they  had  ever  had  any  kind 
of  aural  inflammation,  even  in  childhood.  They  did  not  suffer 
from  naso-pharyngeal  catarrh,  and  never  had  suffered  from  it. 
The  hearing  distance,  as  tested  by  the  watch,  was  normal,  and 
the  tuning-fork  was  heard  equally  well  on  both  sides  of  the 
head.  Such  persons  are  very  rare  in  any  community,  and  con- 
sequently I  have  only  as  yet  examined  seventeen  membranes 
belonging  to  this  class.  From  these  cases,  and  the  observations 
of  others,  I  determine  that  the  color  of  the  membrane  may  vary 
from  a  neutral  gray  to  a  dark  blue  ;  but  it  is  rather  more  in- 
clined to  a  gray  than  to  a  blue.  The  lustre  and  transparency 
vary  exceedingly ;  the  membrane  may  be  very  brilliant  and 
transparent,  so  that  the  stapes  is  seen  through  it,  and  it  may  be 
quite  dull  and  hazy  in  appearance. 

The  light  spot  at  the  end  of  the  malleus  is  usually  triangular 
in  shape,  although  not  always.  It  is,  perhaps,  always  present 
in  some  form  if  the  hearing  be  normal.  The  head,  handle,  and 
short  process  of  the  malleus  are  plainly  visible.  There  may  be 
opacities  at  the  margin  of  the  membrane,  where,  as  Troltsch 
showed,  the  mucous  membrane  is  thickest.  The  gray  color  may 
be  modified  by  a  delicate  pinkish  injection  along  the  periphery 
of  the  membrane  and  handle  of  the  malleus. 

It  is  not  uncommon  to.  find  chalky  spots  or  points  of  calcare- 
ous degeneration  in  the  membrana  tympani.  They  are  found 
not  only  in  the  ears  of  persons  with  impaired  hearing,  but  also 
in  those  whose  hearing  power  is  acute.  Undue  weight  should, 
therefore,  not  be  attached  to  these  appearances. 

Von  Troltsch  *  seems  to  have  been  disposed  to  regard  these 
calcareous  formations  as  connected  with  high  degrees  of  im- 
pairment of  hearing,  but  I  have  not  found  this  to  be  necessarily 
the  case.  Politzer  *  regards  them  as  the  products  of  suppurative 
processes  that  have  run  their  course.  In  some  cases,  as  we 
know,  such  inflammatory  affections  are  perfectly  recovered 
from,  and  if  the  calcareous  degeneration  do  not  occur  on  an 
important  part  of  the  membrane,  it  probably  will  produce  no 
impairment  of  hearing  of  itself. 

Moos  has  proved  by  one  case  which  he  observed,  that  a  cal- 
careous degeneration  may  occur  in  the  course  of  a  non-sup- 


1  Politzer :  The  Membrana  Tympani,  p.  58.  *  Loc.  cit. 


366  CHANGES   IN   MEMBKAXA   TYMPANI. 

purative  process.  This  case  was  that  of  a  woman  more  than 
seventy  years  of  age,  who  had  chronic  catarrh  of  the  middle 
ear. 

Calcareous  degenerations,  as  shown  by  the  microscopic  ex- 
aminations of  Politzer,  usually  occur  in  the  fibrous  layer.  Where 
the  deposit  was  not  very  thick,  the  integument  was  quite  easily 
separated  from  the  calcified  parts.  The  mucous  layer  was  a 
little  more  adherent.  In  some  cases  both  the  external  and  mid- 
dle layers  were  involved  in  the  calcific  process.  Politzer  once 
found  a  true  osseous  deposit,  together  with  the  calcareous  de- 
generation, in  one  of  his  cases.  Black  or  dark  brown  pigment 
was  also  found  by  him  and  fat-globules  everywhere. 

An  acute  catarrh  of  the  middle  ear  in  childhood,  is  sufficient 
to  change  the  color  or  curvature  of  the  membrana  tympani,  and 
thus  render  it  impossible  to  say  that  we  are  dealing  with  a  nor- 
mal membrane.  The  membrana  tympani  of  the  child,  differs 
from  that  of  the  adult,  in  being  more  transparent,  while  it  is 
rather  of  a  yellowish  tinge  than  gray,  and  the  handle  of  the 
malleus  is  not  as  distinctly  seen. 

Politzer  has  shown,  in  his  work  on  this  membrane,  that  the 
triangular  spot  of  light,  which  is  one  of  the  chief  points  for 
study  in  this  part,  is  due  to  the  manner  of  the  reflection  of  light 
from  its  surface,  and  the  factors  which  cause  this  reflection 
have  been  fully  detailed  in  the  chapter  upon  "The  Anatomy  of 
the  Middle  Ear." 

Politzer '  believes  that  we  can  form  no  conclusions  as  to 
changes  in  the  cavity  of  the  tympanum  and  membrana  tym- 
pani, from  alterations  in  the  size  and  shape  of  the  light  spot ; 
but  I  cannot  endorse  this  view.  In  the  first  place,  if  changes 
have  taken  place  in  the  outer  layer,  or  layer  of  epidermis,  the 
reflecting  power  of  the  membrane  is  nearly  removed,  and  there 
is  no  light  spot.  Its  absence  certainly  indicates  changes  in  the 
drum-head.  Again,  if  it  be  smaller  than  usual,  or  if  it  can  be 
changed  in  form  by  the  Valsalvian  experiment,  or  by  other 
methods  of  inflating  the  middle  ear,  I  think  we  may  draw  quite 
positive  and  valuable  conclusions  as  to  the  traction  exerted  by 
the  malleus,  and  as  to  the  inclination  of  the  membrane.  I  do 
not  deny  that  we  may  find  an  irregular  or  small  light  spot  on  a 
person  with  normal  hearing  power  ;  but  I  believe  that  such  a 
state  of  things  is  rare,  and  that  its  shape  and  size  will  be  found 
to  be,  in  the  majority  of  cases,  a  pretty  fair  guide  in  a  general 
way,  as  to  the  loss  of  function.  From  the  notes  of  ninety-four 
ears  affected  with  chronic  non-suppurative  inflammation  of  the 

1  The  Membrana  Tympani,  translated  by  Mathewson  and  Newton,  p.  8. 


TRIANGULAR  LIGHT   SPOT.  367 

middle  ear,  seen  at  the  Manhattan  Eye  and  Ear  Hospital,  and 
recorded  by  Dr.  D.  Webster — 

In  59  the  light  spot  was  present. 
"35       '  absent. 

"9       '  normal. 

"44       '  smaller. 

"     2       '  larger. 

"4       '  divided  (i.e.,  2  or  more  light  spots  existed). 

In  the  last  hundred  cases  of  chronic  catarrhal  inflammation 
of  the  middle  ear,  that  I  have  seen  in  private  practice,  the  fol- 
lowing notes  as  to  the  light  spot  were  made  : 

Well  shaped 16 

Small 48 

None 17 

Two 1 

Interrupted 8 

Fairly  shaped 9 

Very  broad 1 

100 

The  experiments  of  Magnus  in  compressed  air,  which  have 
been  alluded  to  in  the  chapter  on  "In juries  of  the  Membrana 
Tympani,"  also  prove  that  the  non-existence  of  the  light  spot 
does  show,  that  the  membrana  tympani  is  forced  or  drawn 
inward. 

.  CHANGES  IN  MOBILITY  OF  MEMBRANA  TYMPANI. 

If  a  person,  having  normal  hearing  power,  forces  the  air 
into  the  cavities  of  the  tympanum  by  a  prolonged  inspiration 
and  expiration,  with  the  nostrils  closed,  he  has  performed  the 
Valsalvian  experiment  for  testing  the  permeability  of  the  Eus- 
tachian  tubes,  and,  on  examination  during  this  act,  we  find  that 
the  membranes  moved  outward  and  then  inward.  This  change 
takes  place,  in  a  healthy  membrane,  chiefly  at  the  apex  of  the 
light  spot,  or  extremity  of  the  malleus  ;  but  it  may  occur  in 
other  parts,  especially  in  Shrapnell's  membrane.  In  the  ca- 
tarrhal form  of  affections  of  the  middle  ear,  the  mobility  of  the 
drum-head  is  not  affected  to  any  extent.  It  may  be  even  pre- 
ternaturally  movable.  In  the  proliferous  variety,  adhesions  are 
apt  to  occur  between  the  malleus  and  the  membrane,  and  be- 
tween the  other  ossicula,  and  these  will  seriously  affect  the 
normal  movements  of  the  drum-head  and  the  chain  of  bones. 
It  is  true,  however,  that  mere  swelling  of  the  membrane,  such 


368  MOBILITY   OP   MEMBRAINTA   TYMPANT. 

as  obtains  in  the  second  stage  of  the  catarrhal  form,  will,  to 
some  extent,  affect  the  motions  of  these  parts. 

It  should  not  be  thought,  that  the  middle  ear  is  in  a  normal 
condition,  because  a  drum  membrane  moves.  The  membrane 
may  move  well,  and  yet  the  most  serious  changes  may  have 
taken  place  in  the  cavity  behind  it.  Patients  who  suffer  from 
impairment  of  hearing  have  pretty  generally  learned  the  Val- 
salvian  test  or  experiment,  and  when  they  are  so  deaf  as  not 
to  hear  ordinary  conversation  at  all,  and  have  been  so  for 
years,  they  will  often  triumphantl}',  and  with  great  skill,  show 
the  examiner  how  well  they  can  blow  air  into  their  ears,  as  evi- 
dence that  there  can't  be  very  much  the  matter  with  them  after 
all.  The  promulgation  among  the  laity  and  profession  of  the 
valuable  character  of  this  experiment  has  harmed  many  ears. 
It  is  an  experiment  simply.  Its  chief  value  belongs  to  the  ob- 


FIG.  83. — Siegle's  "  Otoscope  "  with  Ely's  Attachment  of  a  Syringe. 

server.  It  is  an  abuse  of  it  to  make  it  a  method  of  treatment.  It 
can  be  theoretically  demonstrated  that  it  is  even  a  somewhat, 
although  slightly,  dangerous  experiment  to  persons  at  all  dis- 
posed to  congestion  of  the  head  and  neck ;  but  this  danger  is  not 
great  enough  to  lead  the  practitioner  to  wholly  abandon  it  as  a 
means  of  treatment,  were  it  not,  as  I  believe,  almost  useless 
therapeutically,  and  dangerous  to  the  integrity  of  the  tension  of 
the  membrana  tympani.  I  very  often  see  patients  who  have 
learned  this  method  of  treatment,  and,  having  believed  that  no 
harm  could  ensue  from  a  very  frequent  performance  of  the  ex- 
periment, have  been  in  the  habit  of  inflating  the  membrana 
tympani  several  times  a  day.  A  membrane  that  has  been  thus 
treated  becomes  very  flaccid,  and  flaps  to  and  fro,  at  every  swal- 
lowing motion. 

Siegle's  instrument,  a  representation  of  which  is  here  given, 
enables  us  to  form  pretty  accurate  notions  of  the  mobility  of  the 
membrane.  The  air  may  be  exhausted  by  means  of  the  lips, 


CHANGES   IN   EUSTACHIAN   TUBE.  369 

while  the  membrane  is  carefully  watched  for  its  movement,  or  a 
syringe  may  be  used,  such  as  Dr.  Ely  attached  to  the  instrument. 
Care  should  be  taken  that  the  speculum,  as  it  should  be  called, 
fit  accurately  in  the  auditory  canal,  so  that  exhaustion  of  the 
air  may  actually  occur.  Of  course,  the  otoscope  must  be  used  to 
examine  the  drum-head  through  the  glass  of  the  speculum. 

CHANGES  IN  THE  EUSTACHIAN  TUBE. 

Having  considered  the  appearance  of  the  drum-head  in  cases 
of  chronic  non-suppurative  inflammation  of  the  middle  ear,  we 
have  next  to  examine  the  Eustachian  tube  and  pharynx,  and 
note  the  changes  which  appear  there.  At  this  point  the  boun- 
dary line  may  be  distinctly  drawn  between  the  catarrhal  form 
and  the  proliferous  form  of  inflammation.  In  the  former  class 
of  cases,  the  pharynx  and  Eustachian  tube  show  marked  evi- 
dences of  morbid  action ;  while  in  the  latter  there  are  scarcely 
any  changes  in  the  pharynx,  and  often  no  very  striking  ones  in 
the  Eustachian  tube.  The  pharynx,  in  a  true  case  of  catarrhal 
inflammation  of  the  middle  ear,  is  found  in  one  of  the  following 
conditions : 

.  There  may  be  great  swelling  of  the  pharynx  and  of  the  ton- 
'sils,  with  or  without  increase  in  the  amount  of  secretion.  There 
may  be,  however,  excess  of  secretion,  without  any  considerable 
swelling.  In  such  cases  the  patient  is  usually  very  conscious  of 
the  trouble  in  his  throat.  He  may  not  be  aware  of  any  pharyn- 
geal  affection,  and  yet  have  a  pharynx  that  is  considerably 
relaxed  and  swollen.  If  these  two  symptoms  be  not  present  to 
any  marked  extent,  we  usually  find  minute  round  elevations 
scattered  over  the  surface,  or  grouped  in  an  arch  under  the 
uvula.  These  constitute  the  disease  known  as  pharyngitis  gran- 
ulosa.  The  pathological  condition  is  a  stoppage  of  the  secre- 
tions, and  subsequently  hypertrophy  of  the  structure.  This 
affection  is  called  by  some  authors  chronic  follicular  pharyn- 
gitis, and  its  more  advanced  stages  glandular  hypertrophy ;  but 
I  prefer  the  simple  nomenclature  of  pharyngitis,  in  the  stage 
of  increased  secretion  and  swelling,  and  granular  pharyngitis, 
when  these  characteristics  of  the  inflammation  are  less  promi- 
nent, but  where  the  granulations  or  hypertrophic  glands  are 
very  marked  in  appearance.  If  the  tonsils  are  not  enlarged, 
they  often  exhibit,  by  a  jagged  appearance,  the  evidence  of  for- 
mer disease. 

Dr.  Wilhelm  Meyer,  of  Copenhagen,  in  1873 '  brought  to  the 


1  Archiv  fiir  Ohrenheilkunde,  Bd.  I.,  Neue  Folge,  p.  254,  Bd.  II.,  pp.  129,  241. 
24 


370  ADENOID   GROWTHS. 

particular  notice  of  the  profession,  a  disease  of  the  naso-pharyn- 
geal  space,  which,  although  known  by  reports  of  isolated  cases, 
seems  never  to  have  been  adequately  studied  until  Meyer  began 
his  investigations.  "Adenoid  growths  in  the  naso-pharyngeal 
space  "  is  the  title  of  Meyer's  first  paper  upon  the  subject.  These 
growths  must  be  known  to  every  practitioner  who  sees  much  of 
naso-pharyngeal  disease,  but  they  do  not  seem  to  be  as  common 
in  our  country  as  in  Denmark.  They  are  developed  in  the  course 
of  a  chronic  inflammation  of  the  pharynx.  They  are  of  two 
varieties  in  shape,  f  ollicular  or  tongue-shaped.  The  first  variety 
is  more  common.  These  cases  have  been  described  by  Czermak, 
Tiirck,  Semeleder,  Voltolini,  and  Lowenberg.  The  latter  author 


PiO.  84. — Pharyngitis  Gramilosa.  This  engraving  was  made  from  a  drawing,  by  Mr.  G.  C. 
Wright,  of  the  pharynx  of  a  young  lady,  who  had  suffered  for  many  years  from  a  chronic  sup- 
purative  inflammation  of  the  middle  ear ;  but  it  is  a  fair  type  of  some  of  the  worst  cases  of 
granular  pharyngitis,  as  seen  in  chronic  catarrhal  inflammation. 

speaks  of  them  under  the  head  of  granular  pharyngitis,  and 
until  Meyer's  papers  were  published  they  were  generally  and 
properly  enough  comprehended  in  this  title.  The  microscope, 
according  to  Meyer,  after  the  examination  of  forty  different 
specimens,  showed  that  these  growths  were  of  the  same  structure 
exactly  as  the  so-called  "  adenoid  tissue  "  of  His.  When  these 
adenoid  growths  or  vegetations  are  found  in  the  pharynx,  the 
surrounding  parts  are  intensely  injected,  swelled,  and  secrete  a 
delicate,  often  greenish  mucus  abundantly.  The  velum  is  most 
swelled,  so  that  it  is  very  much  enlarged.  The  mouths  of  the 
Eustachian  tube  in  this  disease,  according  to  Meyer,  are  very 
often  red  and  swelled,  and  covered  by  mucus  so  tenacious,  that 
it  is  very  difficult  to  remove  it  by  syringing.  In  some  few  cases 
the  mouth  of  the  tube  is  narrowed  to  a  mere  fissure.  Most  of 


ADENOID   GROWTHS.  371 

my  readers  can  verify  this  picture  of  Meyer's  from  cases  they 
have  seen.  Of  175  cases  observed  by  Meyer,  130  were  associated 
with  disease  of  the  ear.  By  far  the  greater -number  were  cases 
of  catarrh  of  the  middle  ear,  while  suppurative  inflammation  of 
the  middle  ear  was  found  in  one-fourth  .of  the  cases.  Of  1083 
cases  of  aural  disease  observed  by  Meyer  in  1869,  1870,  1871,  and 
1872,  adenoid  vegetations  in  the  naso-pharyngeal  space  were 
found  in  about  seven  and  a  half  cases  in  a  hundred.  Meyer 
cautions  us  against  ascribing  too  great  an  importance  to  these 
growths  as  a  cause  of  aural  disease,  for  he  recognizes  the  fact 
that  many  of  these  cases  never  come  under  professional  observa- 
tion and  treatment,  because  the  subjects  of  them  are  sometimes 
troubled  only  with  a  catarrhal  throat,  for  which  they  do  not  con- 
sider treatment  necessary.  I  have  often  been  surprised  at  the 
number  of  cases  of  naso-pharyngeal  disease  of  a  severe  form  in 
which  there  is  no  disease  of  the  ear.  The  intensity  of  a  naso- 
pharyngeal  inflammation  seems  often  to  stop  at  the  mouths  of 
the  Eustachian  tubes.  A  patient  may  have  chronic  naso-pha- 
ryngeal catarrh  all  his  life  and  never  suffer  from  aural  disease. ' 
There  is  no  doubt  since  Meyer's  investigations,  that  adenoid 
vegetations  should  be  distinguished  from  simple  granular  pha- 
ryngitis, with  which  it  may  coexist.  These  growths  affect  the 
physiognomy  and  the  speech,  just  as  do  enlarged  tonsils.  Pa- 
tients speak  "through  their  nose,"  say  "dose"  for  "nose,"  "sogh" 
for  "song,"  and  so  forth.  The  resonance  of  the  voice  is  very 
much  impaired  by  enlarged  tonsils,  and  granular  pharyngitis,  as 
well  as  by  general  hypertrophy  of  the  naso-pharyngeal  mucous 
membrane. 

Examination  by  the  finger  passed  behind  the  palate  is  very 
useful  in  making  a  diagnosis  of  adenoid  vegetations.  The  rhino- 
scope  is  of  course  a  valuable  aid,  but  they  can  usually  be  detected 
by  simple  inspection  of  that  portion  of  the  naso-pharyngeal  space 
to  be  seen  when  the  mouth  is  opened. 

Meyer's  experience,  that  adenoid  vegetations  are  chiefly  seen 
.  in  youth,  is  verified  by  all  observers.  They  are  frequently  asso- 
ciated with  cleft  palate,  according  to  Meyer,  and  Smith  and  Coles, 
quoted  by  him  (Lancet,  1869,  p.  772).  Of  the  prognosis  and  treat- 
ment, something  will  be  said  in  subsequent  pages.2 

The  rhinoscope  will  be  found  a  valuable  assistant  in  a  few 
cases  for  an  exact  diagnosis  of  affections  of  the  naso-pharyngeal 

1  Beverley  Robinson  seems  also  to  have  noted  this.     Transactions   of   American 
Laryngological  Association,  1883. 

2  Meyer's  first  observations  were   published   in   1868,  in   Danish,  and  copied  in 
Schmidt's  Jahrbnch  for  1869,  and  as  he  says  with  candor,  even  before  this,  other  ob- 
servers had  published  striking  cases.     They  escaped  general  notice,  how'ever. 


372  EUSTACHIAN   CATHETER. 

space.  As  a  matter  of  fact,  however,  very  few  of  us  who  treat 
a  great  deal  of  aural  disease,  make  much  use  of  the  rhinoscope. 
It  is  only  in  exceptional  cases  that  we  find  that  its  revelations 
compensate  for  the  time  employed. 

As  I  have  already^  intimated  in  the  second  chapter,  I  use 
much  smaller  catheters  than  those  usually  employed.  Large 
catheters  are  very  difficult  of  introduction,  and  their  use  is  gen- 
erally very  painful  to  the  patient.  I  think  one-half  the  difficul- 
ties encountered  by  the  inexperienced  practitioner  in  the  use  of 
the  Eustachian  catheter,  will  vanish,  if  he  will  be  content  with 
hard-rubber  catheters  of  small  calibre  and  curve. 

Very  many  of  the  patients  who  suffer  from  pharyngitis  and 
naso-pharyngeal  inflammation,  scarcely  speak  of  it  when  asking 
advice  in  regard  to  the  disease  of  the  ears,  and  it  is  only  on 
close  questioning  that  they  will  admit  that  they  are  annoyed  by 
the  accumulation  of  mucus  in  the  throat,  causing  frequent  ex- 
pectoration, hawking,  and  the  other  symptoms  of  chronic  pha- 
ryngeal  catarrh.  At  other  times  the  catarrh,  as  they  term  it,  is 
the  great  burden  on  their  minds,  and  they  talk  freely  of  the 
stuffed  feeling  in  the  head,  and  describe  their  symptoms  in  a 
graphic  style,  that  has  been  obtained  by  a  diligent  perusal  of 
the  advertising  columns  of  the  daily  newspapers. 

The  Eustachian  catheter  is  a  very  valuable  means  of  diag- 
nosticating not  only  the  changes  in  the  cavity  of  the  tympanum, 
but  also  those  in  the  naso-pharyngeal  space.  In  passing  this 
instrument  through  the  nostrils  it  should  always  be  used  as  a 
sound,  and  the  condition  of  this  portion  of  the  mucous  tract 
carefully  noted.  The  inferior  meatus  is  often  found  swollen  and 
even  granular.  In  some  cases  nasal  polypi  may  exist.  There  may 
also  be  an  abnormal  position  of  the  septum  which  renders  the 
canal  very  narrow  and  irregular.  The  manner  in  which  the  air 
passes-  through  the  catheter  into  the  tube  is  deemed  by  many  as 
of  much  importance  in  the  diagnosis  of  chronic  catarrhal  or 
plastic  inflammation.  The  passage  of  a  full  and  strong  current 
almost  necessarily  precludes  the  idea  of  any  considerable  change 
in  the  calibre  of  the  Eustachian  tube,  unless  it  be  atrophy  of  its 
tissue.  The  mere  fact  that  air  can  be  made  to  enter  the  tube, 
either  by  the  Valsalvian  experiment,  the  Eustachian  catheter. 
Toynbee's  or  Politzer's  method ;  in  other  words,  the  fact  that 
the  Eustachian  tube  is  open,  so  that  the  patient  perceives  the 
fulness  in  the  ears,  which  shows  that  a  column  of  air  has  been 
forced  -against  that  already  in  the  middle  ear,  is  no  evidence 
whatever,  that  the  ear  is  in  a  healthy  condition.  In  my  own 
experience,  closure  of  the  Eustachian  tube  is  one  of  the  rarest  of 
conditions.  I  mean  by  closure  such  a  state  of  things,  that,  by 


EUSTACIIIAN   CATHETER.  373 

trial  of  the  catheter  and  Politzer's  method,  the  air  cannot  be 
made  to  enter  the  ear. 

The  two  nostrils  often  differ  very  much  in  size.  This  differ- 
ence is  usually  due  to  a  deviation  of  the  septum  to  one  side  or 
the  other,  in  consequence,  perhaps,  of  an  injury  received  when 
the  patient  was  young,  and  the  bone  was  soft.  In  some  very 
rare  cases  not  even  the  smallest  catheter  that  can  be  made,  can 
be  passed  through  the  nostril  of  one  side.  For  such  cases  the 
catheter  has  usually  been  made  longer,  and  introduced  through 
the  opposite  nostril ;  but  Dr.  Noyes,1  of  this  city,  thinks  that  this 
method  is  not  reliable,  because  by  it  the  air  simply  passes  "  across 
tho  axis  of  the  Eustachian  tube,  and  if  it  pass  up  the  tube  at  all, 
it  can  only  do  so  after  being  reflected  from  the  outer  wall  of  the 
trumpet  orifice." 

Dr.  Noyes  recommends  a  catheter  of  double  curve  for  such 
cases.  The  following  are  his  directions  for  using  it  :  "  When  in- 
troducing the  catheter,  it  is  needful  to  keep  the  front  close  to  the 
septum,  as  well  as  to  the  floor  of  the  nostril.  Arrived  at  the  pos- 
terior edge  of  the  septum,  the  beak  should  wind  closely  around 
it,  curving  obliquely  across,  and  turning  upward,  so  as  to  point 
toward  the  Eustachian  orifice." 

Of  late  years  I  have  scarcely  found  any  cases  where  a  small 
hard-rubber  catheter,  after  the  pattern  figured  in  the  second 
chapter,  could  not  be  used,  and  I  have  ceased  to  use  the  catheter 
of  double  curve,  or  to  pass  one  from  the  opposite  nostril. 

In  order  to  test  the  permeability  of  the  tubes,  the  subsequent 
examination  of  the  membrana  tympani  and  the  patient's  own 
sensations  become  important  evidences.  The  membrana  tym- 
pani may  become  reddened  by  the  mere  application  of  instru- 
ments to  the  external  canal,  and  to  the  mouth  of  the  tube,  so 
that  we  must  be  careful  to  exclude  such  sources  of  error. 

The  diagnostic  tube  of  Toynbee,  by  means  of  which  we  listen 
to  the  sounds  of  the  air  passing  through  the  tube  up  to  the  drum- 
head, is  also  thought  by  many  to  be  of  assistance  in  determining 
the  patency  of  the  tube  and  the  size  of  the  cavity  of  the  tym- 
panum.2 Kramer  claimed  to  determine,  by  the  use  of  the  diag- 
nostic tube,  the  character  of  "exudation"  and  the  width  of  the 
tube.  If  there  is  a  piercing  (durchgehendes),  near,  rattling,  vesic- 
ular sound,  he  then  diagnosticated  the  existence  of  a  free  exu- 
dation. If,  however,  a  sonorous,  near,  vesicular  sound,  it  is 
proof  that  there  is  no  free  exudation ;  if  there  is  a  distant,  muf- 
fled, vesicular  sound,  then  we  are  dealing  with  sub-mucous  exu- 


1  Transactions  of  the  American  Otological  Society,  1870. 

2  See  engraving  on  page  73. 


374  DIAGNOSTIC   TUBE. 

dation,  which  is  united  to  free  exudation,  and  so  -on.  I  only 
quote  these  from  the  last  edition  of  Kramer's  book,  to  show  to 
what  lengths  a  man  may  go  in  riding  a  hobby;  for  Kramer's 
hobby  was  the  diagnosis  of  the  affections  of  the  middle  ear,  by 
the  sounds  heard  through  the  diagnostic  tube,  caused  by  blow- 
ing  through  his  catheters. 

The  true  value  of  the  diagnostic  tube  is  only  in  connection 
with  the  other  means  that  have  been  mentioned,  the  appearance 
of  the  membrana  tympani,  and  the  patient's  own  sensations. 

I  think  the  diagnostic  tube  could  well  be  dispensed  with  in 
aural  practice.  Whether  an  Eustachian  tube  is  pervious  or  not, 
may  be  learned  much  more  readily  than  by  listening  with  the 
diagnostic  tube.  The  old  ideas  as  to  the  importance  of  mere 
permeability  of  the  tube,  have  been  properly  lost  sight  of,  in 
the  study  of  the  nature  of  the  inflammatory  changes  in  the 
calibre  of  the  tube  and  in  the  tympanic  cavity.  I  am  unable  to 
get  much  light  as  to  these  points  from  the  use  of  the  tube.  Yet 
I  must  admit,  that  some  of  my  colleagues,  whose  opinion  I  value 
very  highly,  still  use  it. 

PATHOLOGY. 

After  the  clinical  investigations  of  Kramer  and  Wilde,  the 
first  great  advance  that  was  made  in  otology  were  the  dissec- 
tions of  Toynbee.  The  museum  of  preparations  illustrative  of 
diseases  of  the  ear,  in  London,  is  a  memorial  to  Joseph  Toynbee, 
that  will  be  as  enduring  as  scientific  truth.  From  the  time  of 
Toynbee  until  now,  the  dissection  of  ears  of  those  who  were 
known  to  be  deaf  continues  ;  and  from  the  labors  of  Von  Troltsch, 
Schwartze,  Voltolini,  Hinton,  Gruber,  Orne  Green,  Moos,1  and 
others,  we  have  verified  on  the  dead  bodies  diseases  that  have 
been  diagnosticated  in  the  living  one,  but  in  many  cases,  we 
have  only  learned,  from  the  inspection  of  the  ears  of  the  ca- 
daver, what  is  probably  the  condition  of  ears  in  life. 

The  pathological  appearances  in  chronic  catarrhal  inflamma- 
tion are — 

1.  Collections  of  mucus  or  serum  distending  the  cavity  of  the 
tympanum. 

2.  Thickened  mucous  membrane. 

3.  Filling  up  of  the  cavity  by  lymph. 


1  A  Descriptive  Catalogue  of  Preparations  Illustrative  of  the  Diseases  of  the  Ear. 
London,  1857.  Archiv  fur  Ohrenheilkunde,  Bd.  I.-V.  Monatsschrift  fur  Ohrenheil- 
kunde.  Guy's  Hospital  Reports.  Gruber's  Lehrbuch.  Transactions  American  Oto- 
logical  Society.  Moos'  Klinik  der  Ohrenkrankheiten.  Wendt,  quoted  by  Schwartze, 
Pathology  of  the  Ear,  p.  106. 


PATHOLOGY.  £75 


PATHOLOGY  OF  PROLIFEROUS  INFLAMMATION. 

In  the  form  of  inflammation  that  shows  a  higher  formation 
than  the  catarrhal,  there  are  changes  which  may  have  resulted 
directly  from  the  increase  of  secretion  ;  but  the  stage  of  catarrh 
having  completely  passed  over,  or,  in  some  cases,  never  having 
existed,  these  pathological  appearances  may  be  properly  classed 
together  as  evidences  of  what  I  have  ventured  to  designate  the 
proliferous  form.  They  are  : 

1.  Connective-tissue  formations  in  the  cavity  of  the  tym- 
panum. 

2.  The  mucous  membrane  of  the  tube  covered  by  dense  fibrous 
tissue. 

3.  Hypertrophy  of  the  bony  walls  of  the  tube. 

4.  Obstruction  of  the  tube  and  cavity  of  the  tympanum  by 
dense  fibrous  tissue. 

5.  The  stapes  bone  completely  and  firmly  anchylosed  to  the 
margin  of  the  fenestra  ovalis. 

6.  An  exostosis  on  the  inner  surface  of  the  neck  of  the  mal- 
leus. 

7.  Malleus  and  incus  anchylosed  together. 

8.  Firm  bands  of  adhesions  in  the  mastoid  cells. 

9.  False  membrane  on  the  tendon  of  the  tensor  tympani 
muscle. 

10.  Partial  obliteration  of  the  cavity  of  the  tympanum,  by 
adhesions  of  the  membrana  tympani  to  the  labyrinth  wall. 

11.  Hyperostosis  of  the  petrous  bone,  and  anchylosis  of  both 
stapes. 

12.  Atrophy  and  fatty  and  fibrous  degeneration  of  the  tensor 
tympani. 

13.  Thickenings  and  deposits  of  lime,  and  of  large  round  cells 
in  the  connective-tissue  stroma  of  the  fenestra  rotunda. 

14.  Pseudo-membranous  growths,  sometimes  filling  the  whole 
cavity  with  an  irregular  network,  and  sometimes  covering  the 
fenestra  rotunda,  and  the  tympanic  orifice  of  the  Eustachian 
tube. 

These  are  actual  appearances  of  individual  cases,  taken  from 
Toynbee's  catalogue  and  from  the  writings  of  the  other  authori- 
ties whom  I  have  mentioned ;  some  of  them  are  perhaps  con- 
sequences of  suppurative  inflammation,  although  I  have  been 
careful  to  exclude  all  cases  in  which  there  was  loss  of  the  mem- 
brana tympani,  or  other  positive  evidence  of  a  suppurative 
process. 


376  NON-SUPPURATIVE   INFLAMMATION — CAUSES. 

GruberV  account  of  the  pathology  of  otitis  media  hyper- 
trophica  is,  that,  "from  some  cause  or  other,  there  is  first  a 
great  hyperaemia  with  distention  of  the  membrane,  and  in  part 
the  new  formation  of  blood-vessels,  and  increase  of  the  inter- 
cellular fluid.  The  connective-tissue  corpuscles  are  increased. 
The  tissue  of  the  inflamed  mucous  membrane  is  less  moist  than 
in  the  catarrhal  form.  The  new  formations  or  new  elementary 
formations  go  on  to  a  higher  development.  The  most  various 
adhesions  may  occur,  or  a  soft  connective  substance  appears 
which  is  either  evenly  spread  over  the  whole  portion  that  was 
originally  inflamed,  and  thus  leads  to  hypertrophy  of  the  mu- 
cous membrane,  or  it  may  go  on  to  granular  formation.  Many 
of  these  new  formations  may  also  undergo  regressive  meta- 
morphosis-— they  may  undergo  molecular  disintegration,  become 
fatty,  and  be  absorbed." 

CAUSES. 

I  have  endeavored,  in  recording  the  histories  of  about  forty- 
eight  hundred  cases  of  aural  disease  observed  in  private  prac- 
tice, to  give  the  probable  remote  and  proximate  causes.  These 
are  only  to  be  obtained  by  a  strictly  observed  system  of  cross- 
questioning,  since  by  far  the  greater  number  of  patients  ascribe 
their  disease  to  causes  which  are  certainly  very  remote,  if  not 
doubtful,  and  to  others  which  have  certainly  had  no  influence. 
Thus  patients  will  assert  that  their  loss  of  hearing  results  from 
cold,  when  they  cannot  remember  that  they  ever  had  a  severe 
cold  affecting  the  ears,  but  -they  conclude  that  it  must  have  been 
a  cold  ;  others,  again,  declare  that  their  throats  have  always 
been  well,  that  they  seldom  require  to  use  a  handkerchief,  and 
yet  an  examination  will  reveal  a  bad  condition  of  the  naso-pha- 
ryngeal  mucous  membrane. 

Judging  as  well  as  I  am  able,  from  my  experience  in  public 
as  well  as  private  practice,  I  am  disposed  to  consider  the  follow- 
ing as  among  the  most  probable  causes  of  chronic  non-suppura- 
tive  inflammation  of  the  middle  ear : 

Remote. — 1.  A  feeble  state  of  the  system,  due,  for  example,  to 
inherited  or  acquired  syphilis,  phthisis  pulmonalis,  and  so  forth. 

2.  Defective  hygienic  management,  e.g.,  neglect  of  bathing, 
want  of  exercise  in  the  open  air,  lack  of  proper  food,  care  as  to 
dress,  and  so  forth.  . ' ; 

Proximate. — 1.  Repeated  attacks  of  acute  catarrh  of  the  phar- 
ynx and  middle  ear,  a  disease  popularly  known  as  earache. 


1  Lehrbuch  der  Ohrenheilkunde,  S.  516.     Wien,  1870. 


NON-SUPPURATIVE   INFLAMMATION — CAUSES.  377 

2.  Naso-pharyngeal  inflammation. 

3.  Diseases  of  the  lungs  and  bronchial  tubes. 

These  proximate  causes  are  chiefly  to  be  made  out  in  the 
catarrhal  form  of  chronic  inflammation,  while  in  the  prolifer- 
ous form,  the  practitioner  is  often  greatly  in  doubt,  as  to  what 
may  have  been  the  origin  or  exciting  cause  of  the  insidious 
affection  which  goes  on  so  steadily  to  change  of  structure  and 
loss  of  function.  Indeed,  we  are  often  obliged  to  be  content  to 
acknowledge  the  fact  of  change  of  structure  without  being  able 
to  definitely  assign  a  cause  for  it.  Why  the  changes  that  make 
up  a  true  case  of  proliferous  inflammation,  or  one  of  a  bastard 
form  in  which  the  proliferous  element  predominates,  continue 
to  advance  in  spite  of  treatment  and  of  proper  hygienic  manage- 
ment, is  one  of  the  most  disheartening  problems  that  a  practi- 
tioner who  treats  aural  disease  attempts  to  solve.  It  is  not 
strange,  that  cases  of  insidiously  advancing  impairment  of  hear- 
ing, dependent  upon  illy  defined,  but  positive  causes,  have  ex- 
cited the  minds  of  physicians  to  adopt  even  what  may  appear  to 
be  fanciful  means  for  their  cure. 

The  history  of  coryzas  and  earaches,  and  of  chronic  sorer 
throats,  is  usually  distinct  enough  in  chronic  catarrhal  inflam- 
mation, and  even  if  there  be  no  such  history,  then  the  appear- 
ances of  the  pharynx,  and  the  results  of  tactile  investigation  of 
the  tubes,  are  sufficient  to  allow  us  to  determine  just  what  kind 
of  a  process  has  been  going  on. 

It  would  be  interesting  to  accurately  trace  the  origin  of  these 
proximate  causes.  We  should  find,  I  think,  that  the  most  of 
them  were  due  to  neglect,  or  improper  management ;  for  ex- 
ample, the  heads  of  some  children  are  oftentimes  vigorously 
washed  without  being  thoroughly  dried  •  they  are  allowed  to 
remain  in  water  unduly  long  ;  their  legs  and  chests  are  left  un- 
covered in  weather  in  which  strong  men  are  clad  in  beaver- 
cloth,  and  women  in  furs  ;  they  play  about  the  streets,  and  sit 
down,  when  tired  and  warm,  on  the  damp  and  cold  stone  steps 
of  city  houses  ;  they  are  held  thoughtlessly  by  an  open  window 
on  a  cold  day  ;  they  are  warmly  clad  by  day,  but  insufficiently 
covered  at  night ;  in  short,  the  temperature  of  the  body  is  not 
properly  regulated,  and  a  pharyngeal  catarrh  passes  in  an  in- 
stant to  the  tympanic  cavity,  where  it  is  an  acute  catarrh.  If 
the  acute  catarrh  does  not  go  on  to  suppuration,  it  is  half  re- 
covered from  under  the  use  of  anodynes  applied  to  the  outer 
surface  of  the  drum  membrane  ;  in  which  and  the  tympanic 
cavity  a  thickening  is  left  which  forms  a  good  basis  for  a  case 
of  gradual  and  mysterious  middle -ear  trouble,  and  with  no 
known  cause.  In  large  towns  where  the  system  of  drainage  or 


378  NON-SUPPURATIVE   INFLAMMATION — CAUSES. 

sewerage  is  sometimes  imperfect,  foul  air  may  be  forced  back 
through  the  water-pipes,  and  becomes  a  cause,  often  unsus- 
pected, of  catarrhs  of  the  worst  type. 

With  older  people  a  slight  and  neglected  coryza  or  pharyn- 
gitis is  followed  by  a  fulness  in  the  ears,  that  "  will  wear  away," 
and  which  does  wear  away  in  part;  but  if  it  occurs  in  persons 
who  have  no  good  hygienic  habits  in  such  matters  as  bathing, 
eating  and  drinking,  and  so  forth,  it  leaves  behind  a  degree  of 
hyper-secretion  or  proliferation,  which,  as  has  been  said,  is  the 
foundation  for  repeated  attacks,  and,  finally,  of  permanent 
thickening  and  of  adhesions. 

The  syphilitic  catarrh  of  infants  and  young  persons  is  the 
frequent  cause  of  an  affection  of  the  middle  ear,  which,  unlike 
its  frequent  companion,  interstitial  keratitis,  is  one  of  the  worst 
forms  of  disease  in  the  obstinacy  with  which  it  resists  all  treat- 
ment. The  eyes  may,  and  generally  do,  get  well ;  but,  if  once 
the  tympanic  cavities  be  attacked,  intra-auricular  adhesions 
occur,  the  membrana  tympani  is  drawn  inward,  the  nerve  is 
secondarily  involved,  and  the  loss  of  hearing  often  becomes  al- 
most complete. 

There  are  no  peculiar  aural  symptoms,  by  which  we  may 
positively  distinguish  a  case  of  chronic  disease  of  the  middle 
ear  that  was  caused  by  syphilis,  from  one  occurring  in  a  non- 
syphilitic  patient.  Yet  we  may  say,  in  general,  that  a  syphi- 
litic diathesis  seems  to  cause  the  proliferation  of  tissue  to  be 
more  rapid  and  less  amenable  to  treatment.  Schwartze  be- 
lieves tha,t  the  pathological  change  in  these  syphilitic  cases  is  a 
periostitis,  and  this  view  seems  to  be  correct. 

Just  how  it  is,  that  pregnant  women  are  so  often  affected  by 
a  proliferous  inflammation  of  the  middle  ear,  I  am  unable  to 
say  ;  but  it  is  a  fact,  that  many  women  have  told  me,  that  they 
traced  their  impairment  of  hearing  to  their  first  pregnancy,  and 
that  they  became  worse  at  the  birth  of  each  child.  I  am  now  in 
the  habit  of  warning  such  patients  that  great  attention  should 
be  paid  to  their  throat  and  ears,  by  means  of  gargles  and  Po- 
litzer's  method,  during  the  period  of  utero-gestation.  It  is  the 
proliferous  form  of  inflammation,  and  not  the  catarrhal,  which 
I  have  usually  observed  during  such  cases. 

Proliferous  inflammation  of  the  middle  ear  is  often  produced 
by  cerebro-spinal  meningitis.  In  scarlet  fever  and  measles,  we 
are  more  apt  to  have  suppuration  than  in  the  former  disease. 
It  has  been  supposed  that  disease  of  the  internal  ear,  is  more 
frequently  produced  by  cerebro-spinal  meningitis,  than  that  of 
the  tympanum  and  Eustachian  tube.  This,  I  think,  is  an  error  ; 
but  for  a  fuller  discussion  of  this  subject,  I  refer  the  reader  to 


NON-SUPPUKATIVE  INFLAMMATION — CAUSES.  379 

the  chapter  on  "Deaf-Muteism."  Parotitis  also  is  a  cause  of 
disease  of  the  middle  ear,  but  more  frequently,  perhaps,  it  af- 
fects the  labyrinth,  if  not  exclusively,  certainly  in  connection 
with  disease  of  the  middle  ear.  This  subject  also  will  again  be 
alluded  to.  The  excessive  use  of  quinine  may  also,  in  rare  in- 
stances, cause  incurable  disease  of  the  middle  ear. 

The  causes  given  by  patients  themselves,  taken  from  my 
note-book,  are  as  follows :  ' '  Stuffy  sensations  in  the  head ; " 
"going  in  the  water  very  frequently;"  "severe  colds  in  the 
head;"  "when  a  child,  the  ears  would  stop  up,  and  would  not 
hear  well  for  a  few  days."  The  first  manifestation  was  "a  roar- 
ing noise  heard  at  night;"  "chronic  sore-throat;"  "great  deal 
of  earache;"  "all  the  colds  from  which  I  suffer  are  in  the  head;" 
"  excessive  grief;"  "a  sound  like  that  of  locusts  was  the  first  in- 
dication of  trouble;"  "by  accident  discovered  that  I  could  not 
hear  from  one  ear;"  "I  have  always  had  a  great  deal  of  sore- 
throat;"  "diphtheria;"  "typhoid  fever."  One  patient  gave  a 
graphic  account  of  a  gradual  loss  of  hearing  from  proliferous  in- 
flammation, in  the  following  words  :  "  Ten  years  ago  I  observed 
that  I  could  not  hear  the  church-bells,  and  in  four  or  five  years 
it  began  to  be  difficult  for  me  to  hear  conversation."  Another 
ludicrously  attributed  his  chronic  catarrh  to  exercise  upon  a 
gymnastic  pole.  Another  was  quite  sure  that  it  resulted  from 
great  mental  anxiety.  These  are  fair  specimens  of  the  causes 
Assigned  by  the  patients  or  their  friends  for  cases  of  the  variety 
sf  aural  disease  now  under  consideration.  Some  of  them  are 
far  from  being  true  causes,  although  the  most  of  them  may  be 
admitted  as  having  at  least  placed  the  system  in  such  a  condi- 
tion that  catarrhal  disease  or  proliferation  of  tissue  was  likely 
to  result.  It  is  undoubtedly  true,  that  any  great  mental  depres- 
sion may  cause  an  attack  of  pharyngitis  in  a  person  disposed  to 
it,  and  that  long  continuance  of  such  a  state  of  mind  will  make 
such  an  affection  incurable. 

We  may,  perhaps,  sum  up  our  knowledge  of  the  causes  of 
chronic  non-suppurative  disease  of  the  middle  ear,  by  stating 
that  they  are  such  as  dispose  to  inflammation  of  mucous  mem- 
brane. Our  increased  knowledge  of  the  pathology  of  this  tissue, 
will  serve  us  in  good  stead  in  investigating  the  affections  of  a 
part  which  is  thoroughly  lined  by  it. 


CHAPTER  XIV. 

CHRONIC  NON-SUPPURATIVE  INFLAMMATION  OF  THE  MIDDLE 

EAR— (Continued). 

Treatment  of  the  Catarrhal  and  Proliferous  Forms. — Constitutional  and  Hygienic  Appli- 
cations to  the  Naso-pharyngeal  Space. — Nasal  Douche. — Cases  of  Acute  Aural  Disease 
caused  by  its  Use. — Gruber's  Method  of  Cleansing  Nares. — Politzer's  Method. — 
Anatomy  of  Nasal  Cavities. — Nebulizers. — Faucial  Catheters. — Removal  of  the 
Tonsils. — Treatment  through  the  Eustachian  Tube. — Air.  —  Steam. — Vapors. — 
Fluids. — Bougies. — Electricity. — Death  from  Improper  Use  of  Catheter. — Dura- 
tion of  Treatment. — Prognosis. 

IN  the  preceding  chapter  a  table  was  given,  showing  at  about 
what  time  in  the  history  of  their  disease,  the  patients  from  whose 
cases  it  was  made  up,  consulted  the  writer.  It  may  be  safely 
asserted,  that  the  most  of  these  persons  never  underwent  any 
serious  or  rational  local  treatment  until  that  time;  so  that  we 
may  assume  that  the  greater  number  of  persons  in  the  United 
States  who  suffer  from  the  form  of  disease  under  consideration, 
are  in  the  habit  of  waiting  for  a  period  of  from  five  to  twenty 
years,  before  they  attempt  to  get  relief. 

We  must  certainly  diminish  the  number  of  these  cases  before 
we  can  hope  for  brilliant  results.  The  neglect  of  aural  thera- 
peutics by  the  last  and  the  preceding  generation  now  recoils 
upon  us.  Patients  come  very  late  for  advice  about  their  ears, 
because  they  have  been  taught,  not  by  the  laity,  but  by  wise 
and  skilful  physicians,  that  it  is  not  prudent  to  meddle  with  the 
ear ;  that  they  will  outgrow  its  diseases,  as  soon  as  their  con- 
stitution is  invigorated;  if  young  girls,  that,  when  the  men- 
strual function  comes  on,  their  ears-  will  rapidly  recover,  and  so 
forth,  while,  during  this  time  of  delay,  adhesions  between  the 
membrana  tympani  and  the  ossicula,  and  the  walls  of  the  cavity 
of  the  tympanum,  have  been  forming,  and  hypertrophy  of  the 
mucous  membrane  and  atrophy  of  the  tendons  of  the  intra-auric- 
ular  muscles — in  short,  all  the  changes  have  occurred,  that  we 
have  found  may  take  place  in  the  tympanum  and  drum-head. 

In  one  respect  the  treatment  of  a  catarrhal  non-suppurative 


NON-SUPPURATIVE   INFLAMMATION — TREATMENT.  381 

inflammation  may  be  fairly  distinguished  from  that  of  the  pro- 
liferous form.  In  the  catarrhal  form  we  must  give  a  great  deal 
of  attention  to  the  naso-pharyngeal  space,  while  in  the  other  we 
scarcely  need  to  treat  it.  Perhaps  we  may  classify  the  treat- 
ment generally  advised  as  follows  : 

1.  Constitutional  and  hygienic. 

2.  Local  blood-letting  and  counter-irritation. 

3.  Applications  to,  and  operations  upon,  the  naso-pharyngeal 
space  (chiefly  applicable  to  the  catarrhal  form  of  the  disease). 

4.  Applications  to  the  Eustachian  tube. 

5.  Applications  to  the  cavity  of  the  tympanum. 

6.  Cutting  operations  upon  the  membrana  tympani  and  the 
ossicula. 

In  the  text-books  of  Wilde  and  Toynbee  (books  that  have 
deservedly  had  a  wide  circulation  in  this  country,  and  have 
done  much  to  call  attention  to  the  ear)  constitutional  remedies 
figure  very  largely  in  the  treatment.  The  use  of  mercury  and 
iodide  of  potassium  is  strongly  insisted  upon.  We,  of  the  pres- 
ent time,  have  grown  very  skeptical  about  the  constitutional 
treatment  of  such  affections  as  chronic  catarrhal,  and  prolifer- 
ous inflammation  of  the  middle  ear.  No  thoughtful  practitioner 
will  attempt  to  disregard  the  general  indications  of  a  cachexia, 
or  of  a  debilitated  system,  in  which  there  is  chronic  inflamma- 
tion of  the  mucous  membrane  of  the  middle  ear ;  but  the  time 
has  probably  gone  by  when  a  person  in  fair  health,  suffering 
from  chronic  aural  catarrh,  and  who  has  no  constitutional  taint, 
will  be  treated  by  alterative  doses  of  the  bichloride  of  mercury, 
followed  by  the  iodide  of  potassium.  Ample  experience  has 
shown  that  we  can  do  nothing  for  these  cases  by  such  a  treat- 
ment, and  I  may  say,  that  it  has  been  abandoned  in  the  infirma- 
ries and  hospitals,  where  large  numbers  of  cases  of  aural  disease 
are  seen.  The  constitutional  symptoms  of  the  earliest  stages  of 
the  disease  were  usually  those  of  a  coryza  or  acute  catarrh,  which 
finally  settled  down  into  an  insidious  and  chronic  process,  when 
it  has  become  impossible  to  trace  the  remote  causes. 

Of  late,  Dr.  Theobald,  of  Baltimore,  has  warmly  advocated 
the  constitutional  treatment,  that  is  to  say,  by  internal  medica- 
tion, of  the  form  of  disease  now  under  discussion,  as  well  as  of 
chronic  suppuration,  and  acute  processes,  but  my  opinions  as  to 
the  general  inefficacy  of  drugs,  under  the  limitations  I  have 
given,  have  not  changed  since  writing  the  above.  Homoeo- 
pathic practitioners  attach  great  importance  to  the  internal  ad- 
ministration of  their  peculiar  medicines,  in  catarrhal  and  sup- 
purative  inflammations  of  the  ear,  but  they  seem  to  use  all  the 
ordinary  local  means  employed  by  the  profession  in  general  as 


382  NON-SUPPURATIVE   INFLAMMATION — TREATMENT. 

well.  Dr.  Houghton  '  recommends  baryta  muriatica,  cotyledon 
umbilicus,  iodine  lachesis,  and  mercurius  dulcis,  nux  vomica  (in 
irritations  of  the  mucous  membrane  of  the  middle  ear,  itching 
in  the  Eustachian  tube,  provoking  swallowing)  for  non-suppura- 
tive  •inflammations  of  the  middle  ear  as  well  as  a  host  of  rem- 
edies for  the  other  diseases  of  the  ear.  As  an  example  of  what 
a  belief  in  the  specific  value  of  internal  remedies  can  produce,  I 
may  quote  :  "As  a  remedy  cinchona  proves  curative  in  these  two 
opposite  conditions  (congestion  and  anaemia),  and  acts  upon  both 
cochlea  and  semi-circular  canals."  .  .  .  Oelsemium  in  con- 
junction with  silicea,  is  said  to  have  restored  the  hearing  in 
forty-eight  hours  in  a  case  simulating  cerebro-spinal  meningitis 
on  the  one  hand,  and  simple  labyrinth  vertigo  on  the  other. 

In  our  northern  climates,  all  people  should  wear  flannel  next 
the  skin,  winter  and  summer,  of  course  varying  the  thickness 
according  to  the  temperature  and  the  strength  of  the  individual. 
Thick  boots  in  the  winter,  and  overshoes  in  the  wet,  are  also 
necessities  for  those  who  wish  to  avoid  catarrhs.  I  also  think 
that  the  temperature  of  a  sleeping-room  should  not  be  allowed 
to  go  down  at  night  to  a  point  below  65°  to  68°  F. ;  these  rules  are 
especially  applicable  to  persons  disposed  to  inflammations  of  the 
naso-pharyngeal  space  and  ears.  A  whole  chapter  might  easily 
be  written  upon  this  subject  of  personal  hygiene.  These  hints, 
however,  will  be  sufficient  to  induce  the  practitioner  to  give 
special  attention  to  the  subject  in  prescribing  for  chronic  and 
advancing  aural  disease. 

The  causes  of  these  forms  of  disease  suggest  a  kind  of  con- 
stitutional treatment,  which  should  never  be  lost  sight  of. 
Everything  that  will  render  a  patient  more  vigorous,  and  less 
likely  to  take  cold,  will  assist  materially  in  curing  or  alleviating 
a  chronic  aural  catarrh.  We  shall  thus  find  much  to  do,  in  the 
way  of  correcting  improper  habits  of  life,  in  regard  to  bathing, 
exercise  in  the  fresh  air,  ordinary  clothing,  sleeping  apparel,  and 
the  like.  Hence  the  Turkish  bath,4  sponge-bathing,  walking, 
riding,  boat-rowing,  the  general  application  of  electricity,  the 
internal  administration  of  iron,  and  so  forth,  become  prescrip- 
tions which  the  otologist  will  be  called  upon  to  give  very  fre- 
quently, if  he  properly  appreciates  cause  and  effect.  It  is  only 
against  specific  drugs,  where  there  is  no  specific  diathesis, 


1  Homoeopathic  Therapeutics  in  Aural  Surgery. 

2  The  Turkish  bath  is  one  of  the  best  means  of  keeping  the  circulation  so  equable 
that  catarrhs  do  not  readily  occur.     It  is  not  a  good  plan,  however,  to  allow  the  head 
to  be  wet,  during  the  shampooing  process  that  follows  the  hot-air  bath,  neither  should 
patients  disposed  to  aural  disease,  take  the  cold  plunge  which  is  often  given  at  the  ter- 
mination of  the  whole  process. 


TREATMENT   OF   PHAKYNX.  383 

against  a  routine  system  of  prescribing  a  constitutional  remedy 
in  the  vague  hope  that  it  may  do  good,  that  I  have  been  speak- 
ing. 

The  use  of  leeches  in  some  cases  of  chronic  catarrhal  inflam- 
mations that  have  sub-acute  tendencies,  is  occasionally  of  value, 
although  they  give  no  such  marked  relief  as  that  which  is 
experienced  in  acute  inflammation.  When  there  are  decided 
symptoms  of  congestion,  such  as  fulness  and  slight  pain,  a  leech 
may  be  applied  on  the  tragus  once  a  week,  for  four  or  five 
weeks.  Blisters  are  also  of  value  in  such  cases. 


TREATMENT  OF  THE  PHARYNX. 

The  treatment  of  the  pharynx  may  be  classified  as  follows  : 

1.  Injections  of  the  naso-pharyngeal  space. 

2.  Gargling. 

3.  Cauterizations. 

4.  Removal  of  the  tonsils,  large  granulations,  and  of  ade- 
noid growths. 

Injections  of  the  naso-pharyngeal  cavity  by  means  of  the 
naso-pharyngeal  syringe,  and  by  Davidson's  double-bulbed  syr- 


FiG.  85. — Posterior  Nares  Syringe. 

inge  usually  used  for  enemata,  I  have  found  very  valuable  in 
the  treatment  of  chronic  catarrhal  inflammation.  The  solutions 
I  use  are  common  salt,  permanganate  of  potash,  gr.  £  ad  §  j.,  a 
saturated  solution  of  chlorate  of  potash,  tar-water  benzoate  of 
sodium,  and  so  forth.  Great  masses  of  muco-purulent  material 
are  often  dislodged  by  this  treatment,  even  in  cases  where  ordi- 
nary inspection  does  not  show  that  any  has  collected.  The 
nasal  douche  is  very  frequently  used  for  the  purpose  of  cleans- 
ing the  naso-pharyngeal  space,  but  it  is  a  means  of  treatment 
that  is  attended  with  considerable  danger  to  the  ear,  even  when 
all  proper  precautions  are  taken. 

The  posterior  nares  syringe  is  made  of  hard  rubber.  It  is  a 
very  efficient  and  safe  means  of  cleansing  the  pharynx  and  nos- 
trils. In  cases  of  acute  inflammation  of  the  pharynx  attended 
with  considerable  swelling,  it  should  be  used  with  care,  or  it 
will  abrade  and  irritate  the  mucous  membrane  of  the  posterior 
pharyngeal  wall.  This  abrasion  may  then  lead  to  an  extension 


384  NASAL   DOUCHE. 

of  the  inflammation  along  the  tube,  to  the  tympanic  cavity.  In 
chronic  cases  I  have  never  seen  or  heard  of  any  harm  being 
done  by  the  posterior  nares  syringe. 

Davidson's  syringe  is  also  a  safe  and  useful  instrument  for 


FIG.  86. — Davidson's  Syringe,  with  a  Nozzle  to  go  below  the  Soft  Palate. 

cleansing  the  nares.     It  may  be  used  anteriorly  or  posteriorly. 
Of  late  years,  I  use  it  more  than  I  do  the  posterior  nares  syringe. 


THE  NASAL  DOUCHE. 

I  have  published  several  cases  that  illustrate  the  dangerous 
consequences  that  may  result  to  the  ear  from  the  use  of  the 
nasal  douche,  and  I  was  the  first  writer  to  call  attention  to 
this  subject.  The  appliance  is  so  convenient  of  application, 
and  it  is  thought  to  be  so  thorough  in  its  work  of  cleansing 
the  nostrils  and  pharynx,  that  many  are  very  loth  to  abandon 
it.  I  am  of  the  opinion,  however,  that  its  use  should  be  dis- 
countenanced by  the  profession.  Various  criticisms  have  been 
made  upon  the  published  cases  of  injury  to  the  ear  from  the 
use  of  the  douche,  but  I  believe-  that  they  have  been  fully  met, 
and  that  most  of  the  otologists  on  this  side  of  the  water,  are 
agreed  that  the  nasal  douche,  even  when  employed  with  all 
proper  precautions,  has  produced  serious  aural  symptoms  in 
quite  a  large  number  of  cases.  The  harmful  results  are  prob- 
ably due  to  the  entrance  of  a  large  quantity  of  fluid,  in  a  flood, 
as  it  were,  into  the  cavity  of  the  tympanum  along  the  Eusta- 
chian  tube,  and  necessarily  in  a  direction  contrary  to  the  motion 
of  its  ciliated  epithelium. 

The  use  of  the  nasal  douche  was  first  suggested  by  Professor 
Theodore  Weber,  of  Halle,  Germany,  and  is  based  upon  a  phys- 
iological fact  that  was  first  promulgated  by  Dr.  E.  H.  Weber, 
of  Leipsic,  in  1847.  This  fact  is,  that  when  one  side  of  the  nasal 
cavity  is  entirely  filled  with  fluid  by  hydrostatic  pressure,  while 
the  patient  is  breathing  through  the  mouth,  the  soft  palate  com- 
pletely shuts  off  the  superior  naso-pharyngeal  space  from  the 
mouth,  and  does  not  permit  any  of  the  fluid  to  pass  downward. 


NASAL   DOUCHE.  385 

The  fluid  then  parses  into  the  opposite  nasal  cavity,  and  escapes 
through  the  nostril.  Professor  Theodore  Weber  suggested  the 
use  of  a  cup,  to  the  bottom  of  which  was  attached  a  bit  of  rub- 
ber tubing,  for  the  purpose  of  taking  advantage  of  this  physio- 
logical principle.  The  fountain  syringe  is  now  generally  used 
instead  of  the  cup.  Dr.  J.  L.  W.  Thudichum  brought  this  appa- 
ratus to  the  notice  of  the  English-speaking  profession,1  and  made 
it  more  convenient,  so  that  in  America  it  has  acquired  the  name 
of  Thudichum's  douche.  It  should,  however,  be  called  Weber's 
douche. 

As  early  as  1869,  I  had  found  that  the  nasal  douche  was 
sometimes  a  troublesome  and  dangerous  appliance,  and  I  added 
a  note  to  indicate  this,  in  my  translation  of  "  Von  Troltsch  on 
the  Ear"  (second  edition, .  page  369) ;  but  I  was  not  fully  con- 
vinced that  it  would  readily  cause  acute  aural  inflammation, 
until  the  following  case  occurred  in  my  practice.  The  case  has 
been  amplified  from  the  first  record  that  appeared,2  in  order  to 
avoid  the  reiteration  of  explanations,  that  the  criticisms  upon 
the  case  in  the  Monatsschrift  fur  Ohrenheilkunde,  and  by  Pro- 
fessor Elsberg,  compelled  me  to  make. 

Case  of  Otitis  Media  Purulenta,  and  Pyaemia,  from  the  Use  of  the  Nasal 
Douche. — On  December  12, 1868, 1  was  consulted  by  a  clergyman,  forty-nine  years 
of  age,  in  regard  to  a  sub-acute  catarrh  of  the  middle  ear,  affecting  both  sides 
of  the  head.  The  history  of  the  patient  was  as  follows  :  Some  years  before,  he 
was  attacked  with  what  seemed  to  be  hay  fever,  or  a  form  of  coryza  attacking 
certain  persons  during  the  summer.  This  coryza  became  a  chronic  catarrhal 
inflammation  of  the  naso-pharyngeal  space,  attended  by  the  usual  symptoms — 
a  sense  of  stuffiness  of  the  nostrils,  frequent  expectoration  of  glairy  mucus, 
sneezing,  and  so  forth.  For  the  past  two  months  the  patient  has  been  in  the 
daily  habit  of  using  Weber's  nasal  douche,  for  the  purpose  of  cleansing  the 
nostrils  and  of  introducing  remedial  agents  into  them.  He  had  once  before 
tried  this  means  of  treatment,  but  it  had  caused  such  unpleasant  feelings  in 
the  ears  that  he  was  obliged  to  desist  from  employing  it.  A  warmer  solution 
was  always  used  in  the  douche,  and  it  was  employed  under  the  direction  of  a 
physician  who  was  probably  well  aware  of  Dr.  Thudichum's  directions,  and  took 
all  the  precautions  which  he  advises  in  his  pamphlet.  This  fact  is  mentioned, 
because  the  advocates  of  the  douche  claim  that  it  never  does  harm  when  properly 
employed.  Dr.  Thudichum  advises  that  a  solution  of  salt  and  water,  or  milk 
and  water,  but  never  pure  water,  should  be  used,  as  did  Professor  Weber  some 
time  before.  The  patient  was  also  instructed  to  breathe  through  the  mouth, 
and  Dr.  Thndichum  observed  that  very  often  patients  became  confused,  strag- 
gled, breathed  through  the  nose,  and  defeated  the  plan.  It  is  during  this  ex- 
citement, that  the  accident  of  entrance  of  fluid  into  the  ear  seems  usually  to 
occur.  For  about  two  weeks  these  unpleasant  sensations  on  using  the  douche 


1  On  Polypus  in  the  Nose  and  Ozoena.    London,  1869.    Lancet,  November  24,  1864. 
1  Archives  of  Ophthalmology  and  Otology,  Bd.  I. 
25 


386  NASAL    DOUCHE. 

have  been  again  experienced.  The  patient  complains  of  being  deaf,  and  of  hav- 
ing a  full  sensation  in  both  ears,  almost  amounting  to  pain.  The  membrana 
tympani  of  each  side  is  found  to  be  reddened.  An  ordinary  ticking  watch, 
heard  by  a  person  with  normal  hearing  power  about  six  feet,  is  only  heard  when 
placed  in  contact  with  the  auricle  of  each  side.  A  leech  was  applied  to  each 
ear,  on  the  tragus,  the  Eustachian  tubes  were  rendered  pervious  by  means  of  the 
catheter  and  Politzer's  method.  In  a  few  days  the  membrana  tympani  assumed 
a  normal  appearance,  and  the  hearing  was  restored  by  means  of  this  treatment. 
The  patient  then  desired  that  an  attempt  should  be  made  to  relieve  the  trouble 
in  the  naso-pharyngeal  region.  The  uvula  and  tonsils  were  relaxed,  the  whole 
mucous  membrane  of  the  upper  pharyngeal  space  secreted  excessively,  and  the 
patient  had  contracted  a  habit  of  constantly  endeaving  to  clear  his  nostrils. 
Fluids  passed  through  the  left  nostril,  but  none  through  the  right.  The  Eus- 
tachian catheter,  however,  passed  without  difficulty.  The  nostrils  were  cleansed 
by  means  of  a  nebulizer,  salt  and  water  being  used  in  it,  after  which  the  parts 
were  swabbed  out  with  a  solution  of  arg.  nit.,  gr.  x.  ad  §  j.  The  patient  improved 
under  this  treatment  until  January  28th,  when  he  was  for  some  time  exposed  to 
the  air  of  a  winter's  day,  with  the  head  uncovered  (at  the  consecration  pf  a 
bishop),  when  the  symptoms,  which  had  been  to  a  certain  extent  relieved,  re- 
turned. 

January  31st. — A  gelatinous  mass  was  found  plugging  up  the  inferior  meatus 
of  the  right  nostril,  seeming  to  be  attached  to  the  floor  of  the  canal.  Portions 
of  this  were  removed  by  torsion,  at  intervals  of  about  three  days,  until  Saturday, 
February  6th,  when  what  seemed  to  be  the  remainder  of  this  growth  was  re- 
moved. The  patient  left  the  office,  saying  that  his  nostril  was  much  clearer, 
and  went  to  Yonkers,  a  city  about  fifteen  miles  by  rail  from  New  York.  There 
he  again  used  the  nasal  douche,  and  again  experienced  a  decidedly  iinpleasant 
sensation  in  his  ears,  which,  however,  did  not  amount  to  pain.  On  Sunday 
morning  and  evening  the  patient  performed  his  clerical  duties,  but  with  a  great 
sense  of  languor  and  uneasiness.  On  Sunday  night,  February  7th,  at  about  11 
o'clock,  he  was  awakened  by  a  severe  pain  in  the  mastoid  region  of  the  right  ear, 
which  kept  him  from  sleep.  I  saw  him  Monday  morning,  at  about  8  o'clock, 
and  noted  the  following  symptoms  :  The  countenance  was  anxious  and  flushed, 
the  skin  hot,  pulse  about  96,  right  mastoid  region  red  and  sensitive,  right  mem- 
brana tympani  reddened,  watch  only  heard  when  pressed  upon  the  auricle. 
The  patient  was  asked  as  to  the  condition  of  the  left  ear ;  but  he  said  there 
was  no  trouble  there.  An  examination  of  the  tragus  and  mastoid  process  failed 
to  exhibit  any  symptoms  of  inflammation  in  that  ear.  Two  leeches  were  or- 
dered to  be  applied  to  the  mastoid  process,  and  the  patient  was  to  take  aq. 
acetat.  amm.  At  5  P.M.,  the  pain  in  the  ear  had  entirely  ceased  after  the  appli- 
cation of  the  leeches.  The  patient  was  breathing  hurriedly,  however,  his 
pulse  was  weak  and  frequent — about  96 — and  he  complained  of  pain  and  ten- 
derness in  the  abdominal  region.  Morph.  sulph.,  gr.  £,  was  ordered  to  be  taken 
pro  re  nata,  and  a  poultice  was  applied  over  the  abdomen.  Tuesday,  February 
9th. — The  patient  took  two  powders  of  morphine,  and  passed  quite  a  comfortable 
night.  This  morning  he  complains  of  pain  in  the  forehead,  but  has  none  in  any 
other  part  of  the  body.  The  surface  of  the  body  is  dry  and  hot.  Ordered  aq. 
acetat.  ammon.  and  nutritious  diet.  February  10th. — Last  night  the  patient  was 
attacked  by  a  severe  pain  and  swelling  of  the  left  foot,  and  at  about  7.30  A.M. 
lie  had  a  severe  chill,  lasting  about  fifteen  minutes,  not  followed  by  sweat- 


NASAL    DOUCHE.  387 

ing.  At  this  time  a  discharge  appeared  from  the  left  ear.  There  has  been  no 
pain  experienced  in  this  part.  He  has  not  slept  well,  and  his  general  appear- 
ance is  bad.  Countenance  anxious ;  breathing  labored ;  pulse  96.  The  left 
ankle  and  dorsal  region  of  foot  are  red,  greatly  swollen,  and  tender.  Left  mem- 
brana  tympani  ulcerated  and  discharging  freely. 

Dr.  Foster  Swift  was  called  in  consultation,  and  the  following  treatment 
agreed  upon  :  The  foot  was  wrapped  in  an  alkaline  lotion.  Vichy  water  was 
given  ad  libitum,  with  beef-tea  and  wine ;  morphine  pro  re  nata.  February 
llth. — Patient  does  not  seem  so  well ;  respiration  is  hurried  ;  the  intellect  is 
somewhat  clouded ;  pulse  about  the  same  ;  face  of  a  sallow  hue.  The  stimu- 
lants are  increased,  so  that  he  now  takes  half  an  ounce  of  brandy  in  milk 
punch  every  four  hours,  day  and  night.  Quin.  sulph.,  gr.  ij.,  every  four  hours. 
The  left  ear  is  syringed  with  lukewarm  water,  zinc,  sulph.  applied,  and  Polit- 
zer's  method  used  to  inflate  the  drums.  The  patient  is  so  deaf  that  he  only 
hears  when  spoken  to  near  the  ear. 

The  patient  was  treated  in  this  manner,  until  February  22d,  the  brandy  punch 
being  steadily  increased  until  he  was  taking  two  ounces  every  four  hours,  with 
beef-tea,  eggs,  etc.  His  pulse  was  never  over  100,  usually  about  96 ;  the  skin 
had  a  saffron  hue,  and  patient  lay  in  a  doze,  except  when  the  pain  from  his  foot 
kept  him  awake  nearly  the  whole  time. 

Dr.  George  A.  Peters,  Surgeon  to  the  New  York  Hospital,  was  called  in  con- 
sultation a  few  days  ago,  in  addition  to  Dr.  Swift  and  myself,  and  to-day  two 
openings  were  made  in  the  foot,  one  near  the  internal,  and  one  near  the  external 
malleolus.  Pus  was  evacuated  ;  the  dorsal  region  of  the  foot  was  very  much 
swollen,  but  no  fluctuation  was  detected.  The  patient's  general  condition  is 
now  better ;  his  countenance  less  anxious ;  the  respiration  is  not  so  hurried. 
The  urine  was  several  times  carefully  examined  during  the  treatment.  No  ab- 
normal condition  was  found,  beyond  an  acid  reaction  early  in  the  course  of  the 
disease.  The  heart  was  also  examined,  and  no  organic  changes  were  found. 
Several  openings  were  made  in  the  foot  from  time  to  time  ;  but  the  patient  slowly 
improved  from  this  time  until  March  16th,  when  he  was  able  to  sit  up.  The 
membrana  tympani  healed,  and  the  hearing  distance  became  about  one  foot  on 
the  right  side,  and  four  to  six  inches  on  the  left.  Conversation  is  heard  with 
ease.  Politzer's  method  has  been  practised  every  two  days.  Quinine  and  iron 
have  been  taken  in  addition  to  the  stimulants.  The  foot  is  still  swelled,  but  aJJ 
the  openings  except  two  have  healed.  April  4th. — The  patient  has  been  going 
about  the  house  for  a  week.  Hearing  power  is  still  further  improved.  A  little 
erysipelatous  soreness  of  the  foot  occurred  last  night.  The  naso-pharyngeal 
catarrh  is  completely  gone.  April  7th. — Patient  rode  out  to-day,  and  gets  about 
the  house,  employing  himself  in  intellectual  labor.  Tissues  of  the  foot  still 
swelled  and  rigid  ;  motions  of  the  ankle-joint  unimpaired. 

1884  — I  am  in  the  habit  of  seeing  this  patient  quite  often.  He  is  still  in 
excellent  health,  but  a  very  little  lame  from  the  inflammation  of  the  foot. 

The  late  Professor  Elsberg,  of  this  city,  published  a  paper l 
in  which  he  claimed  that  an  analysis  of  the  cases  that  had  been 
published,  of  harm  to  the  ear  from  the  use  of  the  douche,  showed 


'  Archives  of  Ophthalmology  and  Otology,  vol.  ii. ,  p.  77. 


388 


NASAL    DOUCHE. 


that  the  cause  was  uncertain.  Dr.  Elsberg,  has  had  a  large  ex- 
perience in  treating  diseases  of  the  pharynx,  and  although  he 
has  prescribed  and  employed  the  douche  in  more  than  1600  cases, 
he  has  seen  none  of  the  results  that  I  have  observed.  I  can  only 
explain  this  by  the  presumption,  that  when  an  accident  to  the 
ear  occurs,  the  patients  are  more  apt  to  consult  a  person  who  is 
in  the  constant  habit  of  treating  aural  disease,  than  to  go  on  with 
the  treatment  of  the  nasal  catarrh.  Besides,  as  it  is  believed  by 
many  otologists,  it  is  possible  that  the  douche  sets  up  a  chronic 
inflammation  of  the  tympanic  cavity,  without  any  acute  stage, 
and  thus  the  true  cause  of  an  insidious  chronic  catarrh  is  passed 


PIG.  87.— Vertical  Section  of  Bones  of  Face  (posterior  half,  two-thirds  size.  From  Pro- 
fessor Darling's  museum).  1,  Orbit;  2,  temporal  fossa;  3,  antrum ;  4,  inferior  meatus ;  5, 
middle  meatus ;  6,  superior  meatns ;  7,  zygomatic  process ;  8,  clinoid  process  of  sphenoid 
bone;  9,  septum  nasi ;  10,  inferior  turbinated  bone ;  11,  superior  turbinated  bone;  12,  alveolar 
process ;  13,  ethmoid  cells. 

over,  and  is  supposed  to  be  an  advance  of  the  naso-pharyngeal  in- 
flammation. Of  course,  it  is  not  believed  by  the  author,  that  the 
use  of  the  nasal  douche  will  necessarily  cause  aural  disease,  but 
that  it  is  a  dangerous  means  of  treatment,  which  should  be  care- 
fully watched  by  the  practitioner. 

I  append,  from  a  paper  previously  published,  an  analysis  of 
cases  in  which  serious  results  have  occurred.1  Were  it  expe- 
dient to  further  extend  the  discussion  of  this  subject,  I  could 
add  several  more,  for  I  am  constantly  hearing  of  them  from  my 
professional  friends,  and  seeing  them  in  my  own  practice. 


»Loc.  cit.,  voL  Hi.,  No.  1. 


NASAL    DOUCHE.  389 

Injury  to  the  Ear  from  the  Use  of  the  Nasal  Douche. 


Patient. 

Instructor  '  in  use 
of  douche. 

Fluid  need. 

Ear  disease  pro- 
duced. 

Case  I.  Rev.  Dr.  C. 

A  physician. 

A    warm    solu- 

Acuta otitis  media  sup- 

tion    of    car- 

purativa.     Pyaemia. 

bolic  acid. 

Recovery. 

II.  Dr.  Frank.1 

Dr.  Frank. 

Cold    water, 

Acute  otitis  media.  Re- 

which he  ad- 

covery. 

vises    in    all 

cases. 

HI.  Mr.  D. 

Dr.  Boosa. 

Warm  solution 

Perforation     of     both 

of     salt    and 

membranae  tympani. 

water. 

Recovery. 

IV.  First  of  Dr.  C. 

A  physician. 

Warm   solution 

Otitis   media  suppura- 

I.    Pferdee's3 

of    salt     and 

tiva.     N  ecrosis  of 

cases. 

water. 

middle  ear.     Perma- 

nent deafness. 

V.  Second  of  Par- 

A  physician. 

Salt  and  water. 

Acute  otitis  media.  Re- 

dee's 3  cases. 

covery. 

Medical  student. 

VI.  A  Physician. 

A  physician. 

Unstated. 

Otitis   media  suppura- 

tiva  chronica. 

VH.  Patient  at  Man- 

Unknown. 

Unknown. 

Otitis  media  acuta.  Re- 

hattan Eye  and 

covered. 

Ear  Hospital. 

Vni.  Mrs.   C.     Dr. 

A  physician. 

Warm  fluids. 

Otitis  media  acuta.  Re- 

^Mathewson's 

covered. 

'case. 

IX.  Dr.  Hackley's4 

Unknown. 

Warm   salt 

Otitis   media  suppura- 

case. 

water. 

tiva  chronica,  super- 

vening  on   old    per- 

forations. 

X.  Dr.     Piffard's  6 

Unknown. 

Warm  fluids. 

Otitis  media  acuta.  Re- 

case. 

covery. 

XI.  Judge  . 

A  physician. 

Unknown. 

"Deafness."  Recovery. 

XII.  Dr.  Loring's" 

A  physician. 

Warm  fluid. 

Otitis   media   suppura- 

case. 

tiva  chronica. 

Xin.  Physician.4  Dr. 

A  physician. 

Unstated. 

Otitis  media  acuta.  Re- 

Mathewson's 

covery. 

second  case. 

XIV.  Physician.4  Dr. 

A  physician. 

Unstated. 

Otitis  media  subacuta. 

Mathewson's 

third  case. 

XV.  Physician., 

A  physician. 

Warm    salt 

Fainting  and  otitis  me- 

, water. 

dia  catarrhalis. 

XVI.  Dr.O.  D.Pome- 

Dr.  Pomeroy. 

Warm    salt 

Otitis  media   suppura- 

roy's  case.4 

water. 

tiva. 

1  The  name  or  profession  of  the  instructor  is  given,  in  order  to  meet  the  point  made 
by  the  advocates  of  the  douche,  that  no  harm  occurs  when  it  is  properly  employed. 
8  Archiv  fur  Ohrenheilkunde,  Bd.  V.,  p.  202. 

3  The  Medical  Gazette,  vol.  vi.,  No.  23.     Medical  Record,  February  1,  1870. 

4  Reported  in  Archives  for  Ophthalmology  and  Otology,  vol.  iii.,  No.  2. 

6  Reported  by  Dr.  Pardee,  loc.  cit.  b  Verbal  report  to  writer. 

Dr.  Pardee,  in  his  paper  in  the  Medical  Gazette,  claims  that  the  douche  is  an  in- 
efficient, as  well  as  dangerous  instrument.  He  does  not  think  that  the  conformation 
of  the  nasal  passages,  allows  of  their  being  cleansed  by  such  a  flood  of  water  as  comes 
from  the  douche. 


390 


NASAL    DOUCHE. 


I  am  happy  to  say  that  since  the  publication  of  my  warnings 
against  the  use  of  the  nasal  douche,  on  account  of  its  danger  to 
the  ears,  it  has  been  very  generally  abandoned,  and,  when  re- 
commended, it  is  with  many  admonitions  as  to  care  in  its  em- 
ployment. Since  my  publications  on  the  subject,  many  other 
writers  have  urged  the  profession  to  cease  to  recommend  it. 
Among  them  may  be  mentioned  Buck,  Pardee,  Knapp,  Beverley 
Robinson,  Shaw,  Rumbold,  Cornwall,  and  others.  Buck '  makes 
the  assertion,  in  which  I  fully  agree,  that  ''the  introduction  of 
a  fluid  into  the  nasal  passages  in  a  sufficiently  large  quantity 


PlG.  88. — Vertical  Section  of  Bones  of  Face  (anterior  half,  two-thirds  size.  From  Pro- 
fessor Darling's  museum).  1 ,  Anterior  cranial  fossa ;  2,  orbit ;  3,  malar  process ;  4,  alveolar 
process ;  5,  inferior  meatus ;  6,  middle  meatus ;  7,  inferior  turbinated  bone ;  8,  superior  tur- 
binated  bone ;  9,  septum  nasi ;  10,  antrum  ;  11,  crista  galli ;  12,  ethmoid  cells. 

to  bathe  the  orifice  of  the  Eustachian  tube  (no  matter  by  what 
method  it  is  introduced)  is  not  wholly  free  from  the  danger  of 
setting  up  an  inflammation  of  the  middle  ear" 

On  the  other  hand,  such  good  authorities  as  Cassell"  and 
Burnett 3  still  recommend  the  douche,  if  used  with  care. 

Politzer 4  admits  that,  with  all  precautions,  it  sometimes  hap- 
pens; "chiefly  in  consequence  of  an  involuntary  habit  of  swal- 
lowing," that  fluid  enters  into  the  middle  ear  and  causes  evil 
effects.  Politzer,  therefore,  pours  medicated  solutions  into  the 

1  Medical  Record,  March  24,  1877. 

8  New  York  Medical  Journal,  October,  1877,  quoted  from  Dublin  Journal  Med. 
Sciences,  June,  1877.  3  Text-book,  p.  407.  4  Text-book,  translation,  p.  314. 


GRUBER'S  METHOD.  391 

nose  "by  means  of  a  boat-shaped  glass  vessel,"  while  the  head 
is  inclined  backward.  The  patient  is  told  to  bend  his  head  for- 
ward quickly  the  moment  he  is  conscious  that  the  fluid  has 
entered  his  pharynx.  The  fluid,  in  consequence  of  the  closure 
of  the  lower  part  of  the  pharynx,  has  already  entered  the  other 
nostril,  and  then  it  will  escape  freely.  The  patient  should  not 
blow  his  nose  until  a  quarter  of  an  hour  after  the  medicated 
fluid  is  used.  This  method  is  an  awkward  one.  I  recommend 
rather  the  use  of  Davidson's  syringe  as  a  cleanser,  and  that  the 
medicated  applications  be  made  by  a  coarse  spray,  or  by  cotton 
on  a  cotton-holder  properly  curved. 

Gruber's  Method. 

Gruber  adopts  a  method  of  cleansing  and  medicating  the 
naso  -  pharyngeal  space,  for  which  he  claims  superiority  over 
the  naso-pharyngeal  syringe  and  the  nasal  douche.  He  also 
claims  that  his  method  of  treatment  was  promulgated  a  year 
before  the  nasal  douche  was  introduced  to  the  profession — that 
is,  in  1863,  at  a  meeting  of  the  medical  profession  in  Vienna. 
But  Gruber  spoke  of  his  method  only  with  reference  to  aural 
disease, '  while  Weber's  nasal  douche  was  recommended  as  a 
means  of  treating  the  nares.  Gruber's  method  consists  in  the 
use  of  a  two-ounce  hard-rubber  aural  syringe,  the  nozzle  of 
which  is  well  rounded  off,  in  the  following  way  :  The  syringe  is 
filled  with  the  fluid  to  be  injected  and  placed  in  one  nostril. 
The  fluid  is  then  forced  with  more  or  less  vigor  into  the  nostril, 
the  other  being  closed  with  the  finger,  if  the  operator  desires  to 
inject  the  Eustachian  tubes,  but  left  open  if  the  intention  be  to 
simply  inject  the  naso-pharyngeal  space.  "  In  the  force  with 
which  I  empty  the  syringe,  in  the  more  or  less  perfect  closure 
of  the  other  nasal  meatus,  are  found  the  factors  which  more  or 
less  favor  the  entrance  of  fluids  through  the  tubes.  The  latter 
effect  may  also  be  increased,  after  the  syringe  is  removed,  by 
causing  the  patient  to  perform  the  Valsalvian  experiment."  ' 

Gruber  believes  that  it  is  the  root  of  the  tongue,  as  well  as 
the  soft  palate,  that  by  instinctive  contraction  and  lifting  up- 
ward shuts  off  the  superior  from  the  inferior  pharyngeal  space, 
and  prevents  fluids  injected  by  the  nasal  douche  or  by  his 
method  from  passing  downward.  This  statement  is  proved  by 
the  fact  that  when  the  soft  palate  is  destroyed  by  ulceration, 
the  fluid  may  be  made  to  pass  out  of  the  other  nostril,  as  well 
as  if  the  palate  were  sound. 


Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  VI.,  Xo.  4. 


392  NASAL    DOUCHE. 

Gruber  deprecates  much  instruction  to  the  patient  as  to  how 
he  shall  breathe,  or  hold  his  palate,  during  the  injection  of  the 
fluid,  but  he  prefers  to  leave  him  to  his  own  instincts.  I  am 
also  convinced,  that  instruction  to  patients  as  to  how  they  should 
behave  while  applications  are  made  to  the  naso-pharyngeal 
space  are  useless.  I  inform  my  patients  that  they  may  act  as 
they  please.  A  fluid  should  be  used  which  will  do  no  harm  if 
some  of  it  pass  into  the  stomach. 

Dr.  Gruber  fully  corrobates  my  views  that  the  harmful  effects 
of  the  nasal  douche,  are  due  to  the  entrance  of  the  fluid  into  the 
middle  ear,  and  he  shows  that  however  proper  it  may  be  to  in- 
tentionally inject  fluid  in  small  quantities  into  a  diseased  cavity 
of  the  tympanum,  it  is  manifestly  incorrect  to  force  it  into  an 
ear  that  was  previously  healthy,  with  no  restriction  as  to  quan- 
tity, as  is  done  in  the  use  of  the  nasal  douche. 


FIG.  89.— Nebulizer  for  Nostrils  and  Pharynx. 

"The  current  from  the  nasal  douche  is  continuous,  even  when 
the  cavity  of  the  tympanum  is  already  full ;  the  fluid  in  the 
pharynx  attempts  more  and  more  to  enter  into  the  middle  ear, 
and  when  the  pressure  is  very  great,  rupture  of  the  membrana 
tympani  may  occur.  I  have  often  seen  ecchymoses  on  the  mem- 
brana tympani,  that  were  caused  by  the  nasal  douche."  ' 

I  believe  the  posterior  nares  syringe,  the  Davidson's  syringe, 
and  the  nebulizer  have  nearly,  if  not  quite,  supplanted  the  nasal 
douche. 

The  solutions  that  may  be  used  with  benefit  as  gargles  are,  of 
course,  very  numerous.  The  gargle  that  I  most  frequently  pre- 
scribe is  a  saturated  solution  of  chlorate  of  potash,  or  benzoate 
of  sodium,  3  j.  to  the  pint.  Where  there  is  much  granular  pha- 
ryngitis, a  gargle  containing  iodine,  will  probably  be  more  effi- 
cacious. I  am  in  the  habit  of  advising  patients  suffering  from 
chronic  disease  of  the  middle  ear,  suppurative  or  non-suppura- 
tive,  to  use  a  gargle  of  cold  water,  by  Von  Troltsch's  method,  as 
long  as  they  live.  The  gymnastic  exercise  of  the  muscles  of  the 


1  Gruber,  loc.  cit,  No.  8. 


NEBULIZERS — GARGLING.  393 

Eustachian  tube,  is  by  no  means  an  unimportant  means  of  treat- 
ment. 

Gargling  is  a  very  efficient  means  of  cleansing  the  pharynx, 
if  it  be  performed  in  the  manner  advised  by  Von  Troltsch.  The 
fluid  is  held  in  the  back  part  of  the  mouth,  the  head  being  thrown 
well  back,  the  nostrils  closed  by  the  fingers,  and  then  the  motion 
of  swallowing  is  performed.  With  a  little  practice,  the  patient 
will  become  very  proficient  in  this  method.  Those  who  are  skep- 
tical as  to  the  virtue  of  gargling,  and  who  claim  that  the  process 
does  not  cause  the  fluid  to  wash  the  pharynx,  will  be  convinced 
of  the  contrary  by  the  following  simple  experiment :  Let  the 
posterior  wall  of  the  pharynx  be  painted  with  the  tincture  of 
iodine,  and  then  a  gargle  of  starch-water  be  used  in  the  manner 
described,  and  the  characteristic  reaction  will  be  found  in  the 
ejected  fluid. 

Treatment  of  the  mouths  of  the  Eustachian  tubes,  and  of  the 
posterior  pharyngeal  wall,  is  of  great  value  in  the  treatment  of 
catarrh  of  the  middle  ear.  I  usually  use  a  solution  of  sulphate 
of  zinc,  of  five  grains  to  the  ounce,  in  a  nebulizer.  I  also  employ 
nitrate  of  silver  in  weak  solutions,  from  one  to  five  grains  to  the 
ounce.  I  seldom  use  strong  solutions  by  means  of  a  spray,  but 
when  I-  wish  to  use  nitrate  of  silver  in  a  solution  stronger  than 
five  grains,  I  find  the  application  more  safely  made  by  means  of 
a  properly  curved  cotton-carrier.  I  am  using  strong  solutions 
for  simple  catarrhal  cases  less  and  less,  but  I  rely  upon  thorough 
and  frequent  cleansing  by  Davidson's  syringe  and  a  coarse  spray. 
In  the  nebulizer  I  use  a  solution  known  as  Dobell's  solution  very 
much. 

IjL  Acid,  carbol  gr.  vi. 

•  Soda  Bi.  Borat )  -  -  .. 

ct     J       T_  •          i  C  «<*    ftr-   Xll. 

Soda  bicarb ) 

Glycerin 1  j. 

Aquae ad  3  vi. 

M. 

These  applications  are  not  very  unpleasant,  and  they  are 
certainly  very  efficient  in  diminishing  secretion,  and  in  changing 
the  character  of  tissue.  The  use  of  the  solid  stick  is  very  un- 
pleasant to  the  patient,  and  is,  I  think,  to  be  avoided. 

Dr.  O.  D.  Pomeroy,  who  has  done  much  to  introduce  the  ni- 
trate of  silver  treatment  of  the  pharynx  in  aural  disease,  uses  a 
peculiar  instrument  for  making  applications  to  the  mouth  of  the 
tube,  and  for  inflating  the  cavity  of  the  tympanum.1  Although 

1  Transactions  of  American  Otological  Society,  1872. 


394  FAUCI AL   CATHETER. 

Dr.  Pomeroy  names  his  apparatus  a  faucial  catheter,  I  am  in- 
clined to  think  that  its  chief  value  is  as  a  means  of  making  appli- 
cations to  the  mouth  of  the  tube,  and  not  of  inflating  the  middle 
ear. 

The  instrument  consists  of  a  hard-rubber  tube,  seven  and  a 
half  inches  in  length.  Its  breadth  at  its  proximal  extremity  is 
one-fourth  of  an  inch,  but  it  lessens  toward  the  beak,  which  is  a 
little  more  than  one-eighth  of  an  inch  in  thickness.  The  proximal 
extremity  has  a  lip  for  the  adjustment  of  a  rubber  tube.  At 
about  an  inch  and  a  half  from  this  is  a  perpendicular  guide, 
placed  in  an  opposite  direction  to  the  beak  of  the  instrument. 
This  guide  serves  to  show  the  direction  of  the  beak  of  the  instru- 
ment when  in  position.  The  curved  portion  of  the  tube  is  one 
inch  and  three-sixteenths  in  length.  At  a  line  or  a  line  and  a 
half  from  the  end  of  the  beak,  is  an  aperture  of  the  calibre  of  a 
No.  1  Bowman's  probe,  for  the  injection  of  air  or  fluids.  This 
aperture  is  so  placed,  as  to  cause  the  air  or  fluid  to  be  thrown 
from  the  operator,  or  in  the  axis  of  the  Eustachian  tube.  Air  is. 
injected  into  the  mouth  of  the  tube  by  simply  compressing  the 
air-bag,  when  the  catheter  is  in  position.  Fluids,  of  which  a 
drop  or  two  are  sucked  up  at  each  application  into  the  beak  of 
the  instrument,  are  forced  into  the  tube,  in  the  form  of  a  fine 
spray. 

Dr.  Pomeroy  thinks  that  the  use  of  this  instrument  is  ordi- 
narily simpler  than  the  employment  of  Politzer's  method ;  but 
in  this  view  I  cannot  coincide — and  as  a  catheter,  I  hardly  think 
it  will  take  the  place  of  an  instrument  introduced  through 
the  nose.  The  verdict  of  the  profession  has  hitherto  been  for 
the  method  of  Cleland,  as  against  that  of  Guyot,  and  none  of -the 
faucial  instruments  have,  as  yet,  reversed  this  judgment.  The 
faucial  catheter  of  Dr.  Cutter,1  ingenious  as  it  is,  will  hardly 
supersede  the  catheter  in  ordinary  use,  which  is,  as  has  been 
demonstrated,  an  efficient  instrument,  and  one  that  in  ninety- 
nine  cases  out  of  a  hundred  is  readily  introduced,  and  with  no 
"guess-work,"  as  has  been  said,  but  with  an  exact  knowledge 
of  its  position. 

Sulphate  of  zinc,  of  alum,  sesquichloride  of  iron  in  weak  so- 
lutions, Dobell's  solution,  and  so  on,  may  be  used  with  advan- 
tage by  the  patient  himself  during  the  treatment  of  naso- 
pharyngeal  inflammation.  They  are  most  efficient  when  used 
in  one  of  the  nebulizers  that  are  now  so  largely  employed  in  the 
treatment  of  the  throat.3 


1  American  Journal  of  the  Medical  Sciences,  April,  1872. 

*  These  nebulizers,  to  which  so  many  different  names  are  given,  both  here  and 
abroad,  are  actually  modifications  of  Richardson's  local  anaesthesia  apparatus. 


REMOVAL   OF  TONSILS. 


395 


REMOVAL  OF  THE  TONSILS. 

It  will  often  be  necessary  to  remove  the  tonsils,  or  at  least  to 
greatly  diminish  their  size,  during  the  treatment  of  chronic 
catarrh  of  the  middle  ear.  It  is  not  prob- 
able, that  the  tonsils  ever  grow  to  such  a 
size  that  they  press  upon  the  mouth  of  the 
Eustachian  tube,  as  is  sometimes  supposed, 
but  they  may  be  so  large  as  to  seriously 
affect  the  breathing,  the  resonance  of  the 
voice,  and  the  health  of  the  pharynx  and 
chest.  Through  the  last-named  influences, 
enlarged  tonsils  may  keep  up  or  excite  a 
chronic  inflammation  of  the  middle  ear. 
I  invariably  advise  their  removal,  when 
they  are  large  enough  to  have  any  of  these 
injurious  effects,  and  also,  when,  although 
only  moderately  large,  they  are  frequently 
the  seat  of  inflammation,  and  are  honey- 
combed with  the  fistulae  of  former  inflam- 
matory processes.  For  their  removal,  I 
usually  use  the  tonsil  bistoury  here  shown, 
holding  'the  tonsil  forward  by  the  forceps. 
One  assistant  is  generally  needed,  but  in 
many  instances,  in  the  case  of  those  more 
than  thirteen  or  fourteen  years  of  age,  no 
assistant  is  required.  The  patient  will 
often  be  willing  and  able,  to  hold  his 
tongue  down  by  means  of  the  handle  of  a 
spoon  or  a  tongue  depressor.  In  some 
cases,  I  use  Mackenzie's  guillotine,  espe- 
cially with  very  young  children.  I  never 
saw  any  alarming  hemorrhage,  either  in 
my  own  practice,  or  in  that  of  my  former 
preceptor,  Professor  Post,  in  whose  clinic 
I  have  often  seen  this  operation  performed. 
The  only  cases,  in  which  I  would  hesitate 
to  perform  excision  of  the  tonsils,  when  it 
is  required,  would  be  in  that  of  a  person 
known  or  supposed  to  have  a  hemorrhagic 
diathesis.  I  can  but  think,  that  with  ordi- 
nary care,  it  would  be  impossible  to  divide 
a  large  artery.  I  apply  tannic  acid  or 
tincture  of  iodine  after  excision.  I  am  ^^"j 
not  always  able  to  remove,  with  the  bis-  Knife. 


FIG.  91— Tea 
sil  Forceps. 


396  MOUTH-BREATHING. 

toury,  all  of  the  tonsil  that  I  desire  to  remove  at  one  cut,  but 
it  is  very  unusual  for  the  patient  to  decline  to  have  a  second  ex- 
cision performed. 

It  has  generally  been  observed,  that  persons  having  enlarged 
tonsils,  granular  pharyngitis,  adenoid  vegetations,  or  nasal  ob- 
structions, breathe  through  the  mouth.  The  reasons  for  this  are 
evident.  Dr.  Cassels '  has  made  mouth-breathing  the  subject  of 
an  interesting  paper  entitled  "  Shut  your  Mouth  and  Save  your 
Life."  He  quotes  largely  from  Catlin,  celebrated  as  an  observer 
of  the  Indian  tribes  of  this  country,  who  denounced  mouth- 
breathing  in  no  measured  terms  in  his  work  upon  this  subject. 
Catlin  says  :  "If  I  were  to  endeavor  to  bequeath  to  posterity  the 
most  important  motto  which  human  knowledge  can  convey,  it 
should  be  in  three  words,  Shut  your  mouth."  It  is  certainly  of 
the  highest  importance,  that  the  mouth  should  be  kept  closed  in 
ordinary  breathing,  and  if  the  conditions  are  favorable,  that  is 
to  say,  if  the  nostrils  and  pharynx  are  healthy,  this  will  always 
be  done.  I  have  quoted  Cassels'  paper  at  this  point,  that  Cat- 
lin's  remarkable  statements  as  to  the  hearing  power  of  the  In- 
dians of  America  may  be  noticed.  Catlin  claims  to  have  visited 
two  millions  of  individuals,  living  in  a  savage  state  in  150  dif- 
ferent tribes.  Among  this  number,  he  found  only  three  or  four 
deaf-mutes,  and  not  another  individual  who  was  hard  of  hearing 
or  deaf.  None  of  the  chiefs  of  the  tribes  who  were  questioned 
upon  this  point,  could  remember  or  find  an  Indian  who  was  hard 
of  hearing,  and  Catlin  further  says,  according  to  Cassels,  that 
not  a  mouth-breather  was  known  to  exist  in  all  these  tribes. 
Dr.  Ely  wrote  his  friend,  the  late  Lewis  H.  Morgan,  known  to 
many  of  my  readers  as  a  distinguished  ethnologist,  as  to  the 
correctness  of  Catlin's  observations  among  the  Indians,  and  he 
received  the  following  reply  : 

As  a  rule,  so  far  as  my  observation  has  extended,  the  Indians  are  sonnd  in 
hearing  and  in  vision,  both  senses  being  more  acute  than  with  us.  I  have  seen 
cases  of  sore  eyes  among  the  Western  Indians  and  which  may  have  been  attended 
with  defects  in  hearing.  At  the  time,  I  supposed  the  cases  due  to  syphilis, 
which  has  been  a  scourge  upon  some  of  the  tribes. 

If  you  were  to  select  a  hundred  Indians  at  random,  with  a  hundred  white  men 
the  same,  you  would,  as  I  believe,  find  a  larger  number  of  the  former  sound- 
headed,  limbed,  and  sound  in  the  physical  senses  than  of  the  latter.  Moreover, 
on  general  principles  this  ought  to  be  the  fact. 

Yours  truly, 

L.  H.  MORGAN. 

P.  S. — Catlin  was  a  good  observer. 

1  Reprint.     Edinburgh:  Oliver  &  Boyd.     1877. 


MOUTH-BREATHING.       .  397 

I  have  no  doubt  but  that  Catlin  was  correct  as  to  mouth- 
breathers  among  healthy  Indians,  but  he  overlooked  the  fact 
that  they  were  nose-breathers,  not  from  habit,  but  because 
they  had  healthy  naso-pharyngeal  spaces.  Secure  this  for  the 
human  race,  and  they  will  all  breathe  with  the  mouth  closed.  In 
the  writings  of  Catlin,  and  in  Morgan's  note,  there  seems  to  be 
an  overlooking  of  the  fact,  that  Indians  like  the  Spartans,  may 
have  been  the  survival  of  the  fittest.  Delicate  children,  with  the 
snuffles,  will  probably  survive  in  civilization,  when  Spartan  ex- 
posure, or  a  home  in  an  American  wigwam,  would  soon  cut 
them  off. 

A  curette  curved  to  pass  behind  the  soft  palate,  is  a  very  use- 
ful means  of  treating  granular  pharynx  or  adenoid  growths  of 
small  size.  The  practitioner  must  not  attach  too  much  faith  to 
the  local  treatment  of  chronic  conditions  of  the  fauces,  by  nebu- 
lizers, probangs,  curettes,  and  the  like,  or  he  will  sometimes 
be  grievously  disappointed,  and  accuse  himself  of  over-med- 
ication. 

THE    TREATMENT    OF    THE   NOSE. 

Of  late  years  the  authorities  in  nasal  disease  have  placed 
great  stress  upon  operations  upon  the  nasal  cavities,  for  the 
purpose  of  overcoming  narrowing,  or  occlusion.  It  is  very  com- 
mon to  find  a  deviated  septum,  and  consequent  narrowing  of 
the  meatus  of  one  side  in  persons  who  do  not  seem  to  be  aware 
that  they  have  any  trouble  in  the  respiratory  tract.  Again, 
as  has  been  before  observed,  many  patients  suffer  from  nasal 
occlusion  from  various  causes,  including  even  polypi,  without 
being  aware  of  any  impairment  of  hearing.  In  some  cases  they 
have  a  marked  nasal  catarrh,  hypertrophic  or  atrophic  catarrh, 
without  an  aural  symptom.  It  is  not  reasonable  to  conclude, 
therefore,  that  because  a  patient  has  chronic  disease  of  the  tym- 
panum, and  at  the  same  time  nasal  obstruction,  that  the  latter 
is  necessarily  the  cause  of  the  aural  disease.  Even  if  it  were  the 
primary  cause,  there  are  changes  occurring  in  the  tympanum, 
especially  in  the  joints  of  the  ossicles,  that  will  not  be  removed, 
after  operations  upon  the  nasal  cavities  have  completely  restored 
their  normal  calibre,  orliave  ameliorated  or  cured  the  catarrhal 
condition.  Morbid  conditions,  especially  swelling  of  the  mouths 
of  the  Eustachian  tubes,  as  Dr.  Clarence  C.  Rice  has  shown 
me,  may  be  removed  by  treatment,  and  no  change  result  in  the 
hearing  power.  Dr.  Daly,  of  Pittsburg,  read  a  paper  before  a 
section  of  the  New  York  Academy  of  Medicine,  in  which  he  af- 
firmed that  aural  writers  had  neglected  the  relations  between 
the  nose  and  ear  in  their  treatment,  but  our  literature  as  ex- 


398  t  TREATMENT    OF  THE    NOSE. 

hibited  in  these  pages,  and  those  of  other  authors,  does  not 
show  this.  Yearsley,  Troltsch,  Meyer,  and  Pomeroy  have 
dwelt -fully  upon  the  subject,  long  before  operations  upon  the 
nose  became  common,  but  aural  surgeons,  for  reasons  that 
have  been  already  given,  have  not  been  enthusiastic  about 
invariable  relief  to  the  hearing  from  the  removal  of  nasal 
obstruction,  however  important  it  may  be,  to  secure  patency 
of  the  nasal  cavities  on  other  grounds.  Operations  upon  the 
nose,  even  when  performed  under  pressing  indications,  are 
not  without  danger  to  the  integrity  of  the  ear,  from  an  exten- 
sion of  the  inflammation  caused  by  the  operations,  to  the  tym- 
panum. I  have  seen  several  cases  of  serious  otitis  media  result- 
ing from  this  cause  and  also  mild  cases  of  septicaemia. 

The  union  of  practice  in  nasal  and  aural  disease  is  greatly  to 
be  desired.  Ophthalmology  and  otology  have  been  united  as 
specialties  in  Ireland  and  the  United  States,  ever  since  the  days 
of  Sir  William  Wilde,  but  such  a  union  is  unnatural ;  but  every 
aural  specialist  should  be  an  expert  in  naso-pharyngeal  practice, 
and  vice  versa.  The  next  generation  will  probably  bring  this  to 
pass,  and  there  will  be  then  no  complaints  that  aural  surgeons 
neglect  the  thorough  treatment  of  the  nose,  or  that  rhinologists 
cannot  always  discriminate  between  an  affection  of  the  tym- 
panum and  one  of  the  labyrinth.  When  rhinologists  have  ac- 
quired a  larger  experience  in  diseases  of  the  ear,  they  will  not  be 
so  confident,  as  some  of  them  now  are,  of  curing  chronic  aural 
disease  by  removal  of  nasal  stenosis.  It  may  be  questioned 
whether  the  nasal  cavities  are  not  of  more  importance  to  respi- 
ration and  speech,  than  to  the  hearing. 

THE    TREATMENT    THROUGH    THE    EUSTACHIAN    TUBE. 

Among  the  means  employed  in  the  treatment  of  the  Eusta- 
chian  tube,  the  use  of  the  Eustachian  catheter  stands  pre-emi- 
nent. It  is  difficult  to  say  whether  we  treat  the  tube  or  the 
cavity  to  which  it  leads  by  the  means  of  this  instrument.  We 
may  often  very  much  improve  the  hearing  power  of  a  patient 
by  the  introduction  of  the  instrument  between  the  lips  of  the 
tube,  even  when  no  air,  vapor,  or  fluid  is  passed  through  it. 
After  such  a  procedure  it  is  much  more  easy  to  inflate  the  ear 
by  Politzer's  method.  Some  have  rather  hastily,  as  it  seems  to 
me,  concluded  that  all,  or  the  greater  part  of  the  effect  produced 
by  the  catheter,  might  be  had  by  applications  to  the  mouth  of 
the  tube,  and  have  discarded  this  instrument ;  but  I  become  more 
and  more  convinced  after  twenty  years  of  pretty  steady  experi- 
ence in  its  use,  that  the  Eustachian  catheter  is  essential  in  the 


STEAM   THROUGH   EUSTACHIAN   TUBE. 


399 


treatment  of  chronic  non-suppurative  inflammation  of  the  mid- 
dle ear.     The  agents  to  be  introduced  through  it  are  : 

Atmospheric  air, 

Fluids, 

Bougies, 

Vapors, 

Electricity. 

I  have  placed  common  atmospheric  air  first,  because  I  regard 
it  as  the  most  important  of  the  agents  to  be  employed.  It  is, 
however,  not  so  efficient  in  chronic  as  in  sub-acute  or  acute 
aural  catarrh,  where  its  effects  are  almost  magical.  In  fact,  it 
may  be  claimed,  that  there  are  no  idiopathic  affections  for  which 
relief  is  so  immediately  obtained  as  acute  catarrhal  inflamma- 
tion of  the  middle  ear,  where  inflations  of  the  tympanic  cavity 


FIG.  92. — Apparatus  for  Steaming  the  Middle  Ear. 

with  simple  air  are  often  sufficient  to  cause  a  patient,  for  whom 
the  world  of  sound  is  again  open,  to  shed  tears  of  joy. 

Among  the  vapors  employed,  the  vapor  of  water — steam — an 
old  remedy,  is  one  of  the  best. 

Dr.  C.  I.  Pardee '  published  a  paper,  in  which  he  has  care- 
fully noted  the  results  of  six  cases  of  the  most  obdurate  va- 


1  Transactions  of  the  American  Otological  Society,  1870. 


STEAM   THROUGH    EUSTACHIAN   TUBE. 


riety  of  non-suppurative  disease  of  the  middle  ear,  and  in  all 
of  these  there  was  marked  improvement,  both  in  the  hearing 
distance  and  in  respect  to  the  tinnitus  aurium,  by  the  use  of 
steam  through  the  catheter.  Dr.  Pardee  deduced  from  his  cases 
the  practical  lesson,  that  in  the  treatment  of  the  disease  of  the 
tympanic  cavity,  its  condition  of  moisture  or  dryness  should  be 
considered,  and  that  when  dryness  exists,  our  therapeutic  efforts 

should  tend  to  re-es- 
tablish the  normal  se- 
cretion. 

I  am  in  full  accord 
with  Dr.  Pardee's 
proposition,  and  I  do 
not  therefore  use  the 
vapor  of  water  in  the 
strictly  catarrhal 
cases,  but  in  the  pro- 
liferous inflammation, 
where  adhesions  ex- 
ist, with  rigidity  and 
hypertrophy  of  the 
mucous  membrane. 

The  apparatus  re- 
quired for  the  injec- 
tion of  steam  into  the 
cavity  of  the  tympa- 
num, consists  of  the 
following  appliances : 
1.  An  apparatus  for 
generating  the  vapor. 
A  nickel  -  plated 
copper  flask  is  the 
best  for  this  purpose, 
although  a  glass  flask 
used  over  a  sand-bath 
will  do  very  well.  The 
only  objection  to  the  glass  flask  is,  that  the  flame  may  leap 
beyond  the  level  of  the  water  in  the  flask,  and  break  it,  as  has 
often  occurred  to  me.  Two  glass  tubes  are  placed  in  the  cork, 
and  a  very  minute  opening  for  the  escape  of  steam.  A  piece  of 
flexible  rubber  tubing  is  placed  over  each  of  the  glass  tubes.  In 
the  free  end  of  one  of  the  tubes  is  a  nozzle  adapted  to  the  Eu- 
stachian  catheter  ;  in  the  other  a  tip  adapted  to  an  ordinary  air- 
bag. 

2.  A  hard-rubber  Eustachian  catheter.     A  metallic  instru- 


FIG.  93.— Bottle  for  the  Generation  of  the  Vapor  of  Iodine. 
An  ordinary  air-bag  is  used  for  forcing  the  vapor  into 
the  catheter. 


IODINE  AND   CAMPHOR.  401 

ment  cannot  be  used,  on  account  of  its  becoming  too  hot  to  be 
borne.  Many  practitioners  keep  the  catheter  in  place  by  a 
holder  ;  but  I  always  employ  my  fingers  for  that  purpose. 

The  steam  may  be  gotten  up  by  a  gas  burner,  as  shown  in 
Fig.  92,  or  by  an  alcohol  lamp.  If  gas  is  to  be  obtained,  its  use 
is  more  convenient.  The  steam  should  be  forced  in  by  rather 
a  quick  pressure  upon  the  air-bag.  A  slow  movement,  since  it 
causes  a  longer  application,  is  apt  to  burn  the  patient's  nostrils 
or  pharynx.  The  nozzle  should  be  removed  from  the  catheter 
after  each  puff. 

While  I  still  think  that  steam  employed  through  the  catheter 
is  a  useful  means  of  treating  proliferous  inflammation,  I  have 
nearly  given  it  up,  and  substituted  the  application  of  the  vapor 
of  iodine  and  gum  camphor,  chiefly  on  the  ground  of  conve- 
nience. The  latter  may  be  more  easily  used,  and  its  effects 
are,  I  think,  as  useful.  The  practitioner  may  as  well  know, 
however,  before  he  undertakes  these  cases,  as  to  learn  it  by 
bitter  disappointment  afterward,  that  he  will  cure  no  cases  of 
chronic  proliferous  inflammation  of  the  middle  ear.  All  he  can 
hope  for,  is  to  alleviate  some  cases,  and  stay  the  progress  of  a 
few  others.  But  this  subject  of  prognosis  will  be  more  fully 
discussed  in  another  place.  I  use  iodine  and  camphor  in  pro- 
liferous disease,  and  fluids  through  the  catheter  in  those  that 
are  markedly  catarrhal  cases.  The  use  of  iodine  in  the  simple 
way  that  I  now  employ  it,  was  suggested  to  me  by  Dr.  F.  H. 
Rankin,  of  Newport,  formerly  one  of  my  assistant  surgeons  at 
the  Manhattan  Eye  and  Ear  Hospital.  Fig.  93  gives  a  clear  idea 
of  the  apparatus  necessary.  The  patient  holds  the  apparatus  in 
his  hand,  while  the  surgeon  forces  the  vapor  into  the  mouth  of 
the  Eustachian  catheter. 

I  formerly  used  the  vapor  of  iodine  alone,  but  I  now,  at  the 
suggestion  of  Dr.  H.  P.  Farnham,  put  about  two  drachms  of  gum 
camphor  in  two  ounces  of  tincture  of  iodine,  and  force  the  vapor 
from  this  mixture  through  the  catheter.  Besides  having  a  posi- 
tively curative  value,  it  is  very  grateful  and  pleasant  to  the  pa- 
tient. 

FLUIDS. 

After  all  the  experiments  to  determine  whether  fluids  forced 
into  the  tube  through  the  catheter  actually  reach  the  cavity  of 
the  tympanum,  it  is,  I  believe,  pretty  conclusively  settled  that 
they  do,  and  they  may  have  a  decided  effect  upon  the  lining 
membrane  of  this  part. 

Wreden's  experiments  make  it  somewhat  doubtful,  whether 
a  few  drops  of  fluid,  injected  through  the  Eustachian  catheter, 
26 


402 


FLUIDS. 


actually  reach  the  cavity  of  the  tympanum.  All  the  experi- 
ments that  have  been  made  agree,  however,  in  one  fact,  that 
where  a  large  quantity  of  fluid  is  injected  en  masse,  some  of 
it  enters  the  tympanum.  The  usual  method  of  injecting  a  fluid 
into  the  mouth  or  calibre  of  the  Eustachian  tube  is  the  follow- 
ing :  the  Eustachian  catheter  is  introduced  in  the  usual  way, 
the  patient  having  previously  taken  a  little  water  in  his  mouth. 
A  drop  or  two  of  the  fluid  to  be  injected  is  then  placed  in  the 
nozzle  of  the  catheter,  and  at  the  moment  the  patient  swallows, 
it  is  forced  into  the  tube  by  an  air-bag. 

Dr.  F.  E.  Weber,  of  Berlin,  has  invented  an  instrument  for 
spraying  the  tube  and  the  tympanic  cavity.  He  calls  his  appa- 
ratus the  "pharmaco-koniantron."  It  consists  essentially  of  a 
long  and  flexible  Eustachian  catheter,  which  is  passed  into  the 
tube  as  far  as  the  junction  of  the  cartilaginous  with  the  osseous 
portion.  It  is  perforated  laterally  about  1£  mm.  from  its  beak, 
and  it  is  introduced  through  an  ordinary  metallic  catheter.  The 
fluid  is  forced  through  the  lateral  opening  in  the  form  of  spray, 
by  means  x>f  an  air-bag  attached  laterally  to  the  tube  of  a  small 
syringe.  The  fluid  to  be  used  is  first  driven  by  the  syringe  into 
the  nozzle  of  the  catheter,  and  then  forced  forward  by  the  air-bag. 

As  has  been  intimated,  Dr.  Wreden '  does  not  believe,  that 
drops  of  fluid  injected  in  the  manner  that  has  been  described 
through  a  tubal  catheter,  reach  the  cavity  of  the  tympanum, 
but  that  they  pass  only  to  the  osseous  part  of  the  tube.  He  does 
not  deny  that  injections  en  masse  will  reach  the  cavity  of  the 
tympanum,  but  he  thinks  such  injections  dangerous. 

Wreden  advises  the  use  of  the  tympanic  catheter — that  is,  a 
catheter  that  passes  beyond  the  isthmus  of  the  tube,  as  a  vehicle 
for  introducing  drops  of  fluid  into  the  middle  ear.  After  the 
tubal  catheter,  through  which  the  tympanic  one  is  passed,  is  in 
position  and  fastened  by  means  of  a  forehead  band,  and  the 
permeability  of  the  tube  has  been  ascertained  by  the  use  of  a 
probe  1.4  mm.  in  thickness,  the  operator  drops  five  drops  of  the 
solution  to  be  used  upon  a  watch-crystal  or  other  convenient 
receptacle,  draws  it  up  into  the  catheter  and  inserts  the  instru- 
ment as  far  as  the  tympanic  orifice  of  the  tube.  The  drops  are 
then  forced  into  the  middle  ear  by  the  mouth.  Sensations  of 
fulness  in  the  ear,  and  an  increase  of  the  impairment  of  hear- 
ing, usually  occur,  but  they  pass  off  in  from  six  to  twelve  hours. 
In  about  forty-eight  hours  the  beneficial  effect  should  be  seen. 

Wreden  uses  the  following-named  agents  through  the  tym- 


1  Separat-abdruck  aus  der  St.  Petersburger  medicinischen  Zeitschrift,  N.  F.,  Bd. 
I.,  1871. 


FLUIDS.  403 

panic  catheter,  and  he  insists  that  the  maximal  doses  should  not 
be  exceeded,  lest  acute  inflammation  be  excited. 

1.  Fused  caustic  potash,  one-quarter  to  one-half  grain  to 'the 
ounce  of  water. 

2.  Liquor  potassse,  three  to  five  drops  to  the  ounce  of  water. 

3.  Concentrated  acetic  acid,  two  to  three  grains  to  the  ounce 
of  water. 

4.  Pure  iodine,  using  one-eighth  to  one-quarter  of  a  grain  to 
the  ounce  of  a  half  per  cent,  solution  of  iodide  of  potassium. 

5.  Corrosive  sublimate  of  mercury,  one-twelfth  to  one-eighth 
of  a  grain  to  the  ounce  of  water. 

6.  Nitrate  of  silver,  one-quarter  to  one  grain  to  the  ounce  of 
water. 

7.  Sulphate  of  copper,  one-quarter  to  one  grain  to  the  ounce. 

8.  Sulphate  of  zinc,  one  to  two  grains  to  the  ounce. 

9.  Iodide  of  potassium,  two  to  five  grains  to  the  ounce. 

10.  Sulphate  of  atropine,  one-half  to  one  grain  to  the  drachm 
of  water. 

11.  Hydrate  of  chloral,  one  to  two  grains  to  the  ounce  of 
water. 

Wreden  uses  these  agents  through  the  tympanic  catheter, 
chiefly  in  the  proliferous  form  of  inflammation  of  the  middle 
ear.  These  injections  are  made  every  third  or  fourth  day,  for 
from  fifteen  to  twenty  days,  and  although  it  is  not  claimed  that 
the  results  are  brilliant,  they  are  well  worthy  of  a  trial  where 
all  the  ordinary  means  by  a  tubal  catheter  have  failed. 

In  chronic  catarrhal  inflammation  the  agents  named  last  on 
the  list  are  also  used,  but  the  caustic  applications  are  only  ap- 
plied to  the  cases  of  proliferous  inflammation— the  cases  classed 
under  the  head  of  sclerosis  by  Troltsch. 

Kramer  was  perhaps  the  first  to  use  the  tympanic  catheter 
to  any  great  extent,  and  his  instrument  is  essentially  the  one 
that  Wreden  employs.  It  is  a  hard-rubber  catheter,  made  long 
enough  to  reach  the  tympanic  orifice,  and  is  passed  into  the 
tube  through  an  ordinary  tubal  catheter. 

Bishop,  of  London,  invented  a  nebulizer  for  the  faucial 
mouth  of  the  Eustachian  tube  ;  but  it  was  a  very  inconvenient 
instrument,  and  never  came  into  general  use. 

Dr.  C.  E.  Hackley's  instrument  will  be  found  a  more  efficient 
means  of  spraying  the  tube.  Dr.  Hackley's  apparatus  consists 
of  an  air-bag,  an  Eustachian  catheter,  with  a  hard-rubber  nozzle 
to  fit  in  its  mouth,  a  piece  of  rubber  tubing,  and  a  hypodermic 
syringe.1 

1  Medical  Record,  No.  134. 


404  EUSTACHIAN   NEBULIZER. 

"The  nozzle  of  the  air-bag  is  inserted  into  one  end  of  the 
rubber  tube,  the  tip  to  fit  in  the  catheter  being  placed  in  the 
other  end.  The  hypodermic  syringe  is  filled  with  the  liquid  to 
be  employed,  then  its  point  passed  through  the  tube  and  out 
through  the  calibre  of  the  hard-rubber  tip  for  the  catheter,  as 
shown  in  the  cut." 

"The  mouth  of  the  Eustachian  catheter  B  being  fitted  over 
the  hard-rubber  tip  A,  and  held  there,  if  sudden  pressure  is 
made  on  the  air-bag,  while  the  piston  of  the  syringe  is  forced 


FIG.  94. — Hackley's  Eustachian  Nebulizer. 

home,  the  liquid  will  be  thrown  through  the  catheter  in  the 
form  of  spray. 

"  In  using  this  apparatus  for  the  treatment  of  diseases  of  the 
ear,  the  catheter  should  be  carefully  introduced  through  the 
nose,  and  placed  in  position.  Then,  while  the  diagnostic  tube 
is  placed  in  the  ear,  the  hard-rubber  tip  should  be  inserted  in  the 
catheter,  and  air  alone  forced  through  to  determine  whether 
the  catheter  be  properly  in  position.  If  found  to  be  so,  the  piston 
may  be  pressed  on  at  the  same  time  that  air  is  forced  through. 
During  this  experiment  the  catheter  may  be  held  in  position  by 
clamps  for  that  purpose,  or  may  be  held  by  the  fore  and  middle 


POLITZER'S  METHOD.  405 

fingers  of  the  left  hand,  while  the  thumb  of  the  same  hand 
presses  on  the  piston,  the  other  hand  being  used  to  work  the 
air-bag." 

It  is  well  to  have  a  small  round  opening  made  in  the  air-bag, 
as  at  C  ;  while  the  air  is  being  forced  out  this  may  be  closed  by 
the  finger,  which  then  being  removed,  the  air-bag  quickly  fills 
again. 

It  may  be  said  in  general  terms  that  the  use  of  spray  of 
astringent  fluids  to  the  Eustachian  tube,  is  chiefly  of  value  in 
those  cases  in  which  the  evidences  of  catarrh,  or  increased  se- 
cretion, are  strongly  marked,  while  fluids  are  to  be  employed  in 
the  tympanic  cavity,  when  there  is  marked  evidence  of  the  pre- 
dominance of  the  proliferous  form  of  disease. 

The  injections  of  simple  air,  or  of  medicated  vapors,  in  what 
may  be  called  the  mild  cases  of  catarrhal  inflammation,  will  be 
found  quite  as  efficacious  as  fluids  or  spray.  As  has  been  al- 
ready mentioned,  steam  and  iodine  vapors  are  chiefly  applicable 
to  cases  of  proliferous  inflammation. 

I  am  in  the  habit  of  employing  Politzer's  method  of  inflating 
the  drum-cavity,  immediately  after  the  use  of  the  Eustachian 
catheter,  in  all  cases  of  chronic  disease  of  the  middle  ear,  but  I 
cannot  believe  that  it  is  a  substitute  for  the  catheter.  It  is  very 
often  found  that  no  impression  can  be  made  upon  the  tube  or 
middle  ears  by  the  use  of  Politzer's  method  alone,  but  after  the 
catheter  has  been  passed  into  the  mouth  of  the  tube,  and  some 
muscular  spasm  set  up  in  the  abductor  and  dilator  of  the  open- 
ing, that  this  means  of  treatment  becomes  effectual  at  once.  It 
is  not  well,  however,  to  place  the  air-bag  in  the  hands  of  the 
patient  and  advise  him  to  use  it.  Such  advice  will  usually  be 
over-regarded,  and  instead  of  inflating  the  ears  every  other  day, 
it  will  be  done  every  hour  perhaps.  Besides,  patients  are  often 
very  unsuccessful  in  their  attempts  to  drive  air  into  the  ears. 
Of  course  there  are  cases  in  which  this  system  of  self-treatment 
must  be  adopted,  or  none  at  all  can  be  undertaken  ;  but  physi- 
cians who  treat  aural  disease  soon  learn  that,  if  they  wish  to 
achieve  the  best  results,  the  treatment  must  be  carried  on  by 
the  medical  adviser  himself,  and  not  be  delegated  to  lay  au- 
thority. 

Some  years  since,  I  began  to  inject  vapors  into  the  ear  by 
means  of  a  simple  apparatus,1  represented  on  page  75.  The 
apparatus  consists  of  a  hollow  bulb  of  hard  rubber,  which  is  at- 
tached by  a  bit  of  rubber  tubing  to  the  air-bag  used  in  Politzer's 
method.  Any  fluid  that  is  readily  vaporized  is  placed  upon  a 

1  American  Journal  of  the  Medical  Sciences,  vol.  liii.,  p.  62. 


406  BOUGIES. 

sponge  contained  in  the  bulb,  and  on  practising  inflation  of  the 
ear,  the  vapor  is  forced  into  the  Eustachian  tube  and  the  cavity 
of  the  tympanum.  The  tincture  of  iodine  and  chloroform  are 
the  agents  I  chiefly  employ.  Dr.  J.  S.  Prout  taught  me  the  value 
of  chloroform  as  a  means  of  diagnosticating  closure  of  the  tube. 
This  vapor  will  penetrate  the  ear  when  air  or  iodine  are  not  per- 
ceived, and  when  all  attempts  at  inflation  with  air  have  failed, 
or,  as  should  be  said,  when  the  patients  experience  no  sensation 
in  the  ears  from  the  use  of  air  through  the  catheter,  or  by  Po- 
litzer's  method.  Great  caution  should  be  used  in  employing  the 
chloroform  ;  that  is,  but  a  few  drops  should  be  used,  or  the  most 
intense  pain  will  be  caused.  I  have  seen  patients  jump  from 
the  chair  in  surprise  and  pain,  after  one  careful  inflation,  when 
only  two  or  three  drops  were  upon  the  little  sponge  in  the  bulb, 
and  this,  after  attempts  to  cause  a  sensation  in  the  ears  with 
common  air  had  utterly  failed.  The  use  of  chloroform  vapor  is 
certainly  a  very  valuable  diagnostic  means,  although  its  thera- 
peutic value  is  very  limited.  The  hollow  bulb  was  recom- 
mended as  an  inhaler  by  Dr.  Buttles,  of  this  city,  but  it  was 
intended  to  be  used  in  the  nostrils  only.  The  attachment  to 
Politzer's  air-bag  was  first  made  by  myself. 

BOUGIES. 

Bougies,  for  the  purpose  of  dilating  the  Eustachian  tube,  are 
highly  spoken  of  by  some  writers.  Bonnafont  and  Kramer,  were 
perhaps  the  first  to  use  them.  Guye,1  of  Amsterdam,  also  em- 
ployed them,  and  published  three  cases  of  emphysema  produced 
by  their  use.  In  the  first  case  there  was  emphysema  along  the 
neck,  as  far  as  the  sternum.  In  three  days  it  passed  away. 
In  the  second  there  was  suddenly  considerable  dyspnoea.  The 
uvula  was  found  to  be  the  cause  of  the  trouble.  It  was  very 
much  distended  with  air.  An  incision  in  it  was  made  at  once, 
and  the  patient  again  breathed  quietly.  In  the  third  case  a  fold 
of  mucous  membrane  in  the  fauces  became  so  much  swollen 
immediately  after  the  use  of  the  bougie,  that  breathing  be- 
came difficult.  Here,  again,  snipping  the  fold  soon  relieved  the 
breathing. 

These  cases  probably  show  all  the  danger  there  is  in  using 
bougies.  They  are,  however,  somewhat  painful.  Among  some 
five  thousand  private  patients,  I  have  recorded  but  very  few 
cases  in  which,  after  a  fair  trial,  air  could  not  be  driven  into 
the  Eustachian  tube  by  means  of  the  catheter  or  Politzer's 

1  Archiv  f iir  Ohrenheilkunde,  Bd.  II. ,  p.  6. 


BOUGIES.  407 

method.  In  cases  where  common  air  did  not  enter,  the  vapor 
of  chloroform  did.  In  this  fact,  will  be  found  my  reason  for  not 
resorting  to  the  use  of  the  bougie  more  frequently.  Their  use  is 
chiefly  to  stimulate  the  mucous  membrane-  lining  the  Eustachian. 
tube,  and  thus  to  remove  the  swelling.  Complete  stricture  of 
the  tube  is  too  rare  an  occurrence  to  be  really  much  considered 
as  an  indication  for  the  use  of  the  bougies.  I  find  in  injections 
of  vapors  or  fluids  the  stimulant  thus  sought  without  any  of  the 
unpleasant  features  of  the  bougie  treatment,  such  as  the  produc- 
tion of  emphysema,  breaking  of  the  bougie  in  the  tube  and  severe 
pain.  Dr.  Noyes  reports  a  case '  in  which  a  fine  whalebone  olive- 
tipped  bougie  passed  into  both  Eustachian  tubes  through  the 
catheter,  produced  suppurative  inflammation  of  the  middle  ear, 
but  Dr.  Noyes,  as  he  very  recently  told  me,  still  uses  bougies  and 
considers  them  indispensable  for  certain  cases. 

In  the  discussion  which  ensued  on  this  case,  Dr.  Weir  said 
that  he  had  tested  the  merits  of  the  bougie  practice  for  five 
years,  and  felt  that  in  cases  where  obstruction  of  the  Eustachian 
tube  did  not  yield  readily  to  Politzer's  bag,  the  pump,  or  the 
catheter,  the  bougie  was  of  very  material  assistance.  In  a  large 
experience  he  had  met  with  two  accidents,  purulent  inflamma- 
tion of  the  middle  ear,  and  temporary  emphysema  of  the  eyelids, 
face,  and  neck.  These  accidents  occurred  from  neglect  of  certain 
rules  which  he  now  carries  out.  Dr.  Weir  uses  catgut  bougies 
on  which  are  marked  the  length  of  the  catheter,  the  distance  to 
the  isthmus  or  narrowest  part  of  the  tube,  74  mm. ,  then,  the  dis- 
tance from  the  point  to  the  tympanic  cavity,  11  mm.,  and  finally 
the  width  of  the  cavity,  13  mm.  The  bougies  ranged  from  Nos. 
2  to  5  of  the  French  scale. 

Dr.  Weir's  directions  as  to  the  employment  of  the  bougies  are 
so  thorough  and  careful  that  I  quote  them. 

The  instrument  having  been  passed  through  an  ordinary 
Eustachian  catheter,  and  "once  engaged  in  the  tube  is  pushed 
onward  as  far  as  the  isthmus,  allowed  to  rest  then  a  few  mo- 
ments and  then  withdrawn,  and  air  gently  blown  in  through  the 
catheter.  If  the  air  did  not  readily  enter  the  tympanic  cavity, 
all  forcible  attempts  to  force  it  were  carefully  abstained  from 
and  the  bougie  reintroduced,  either  then,  or  preferably  at  an- 
other sitting,  and  carried  only  to  a  very  short  distance,  say  one 
or  two  millimetres  farther  on,  and  the  experiment  resorted  to, 
to  ascertain  if  the  tube  were  open."  Dr.  Weir  has  found  the 
most  obstructions  in  the  first  portion  of  the  tube,  though  in  sev- 
eral instances  he  had  overcome  total  obstructions  at  the  tym- 

1  Transactions  of  the  American  Otological  Society,  Third  Year,  p.  55. 


408  BOUGIES — ELECTKICITY. 

panic  orifice.  "  The  conical  French  bougies  should  be  discarded 
as  dangerous,  from  the  tapering  ends  being  too  long;  but  the 
catgut  bougies  might  be  made  slightly  conical  by  rubbing  them 
on  emery  paper." 

Within  a  short  time,  bougies  have  been  again  recommended 
by  Urbantschitsch,  but  I  have  not  been  able  to  substantiate  the 
opinions  of  those  who  recommend  them  by  my  own  experience. 
I  fear  that  years  of  careful  treatment  of  chronic  proliferous  in- 
flammation in  hospital  and  private  practice,  without  curing  any, 
have  made  me  a  little  too  chary  about  the  use  of  troublesome 
and  severe  remedies  for  cases,  for  which  we  can  expect  no  more 
than  slight  alleviation  and  temporary  improvement. 

ELECTRICITY. 

This  is  an  agent  whose  real  value  has  been  much  under- 
estimated in  many  departments  of  medicine,  but  which  I  am 
inclined  to  believe  has  been  overrated  in  the  treatment  of  aural 
disease.  The  effects  of  electricity  on  the  acoustic  nerve  will  be 
fully  discussed  in  the  third  part  of  this  volume,  while  it  is  only 
necessary  to  say  at  this  point,  that  not  much  is  to  be  expected 
from  the  use  of  electricity  in  chronic  non-suppurative  inflamma- 
tion of  the  middle  ear.  Drs.  Beard  and  Rockwell1  think  that 
"the  best  results  are  obtained  in  those  cases  passing  from  the 
sub-acute  to  the  chronic  stage,  and  that  then  they  are  brought 
about  by  the  mechanical  action  of  the  Faradic  current,  on  the 
adhesions  within  the  middle  ear."  These  are  just  the  cases  that 
are  amenable  to  treatment  by  the  catheter,  Politzer's  method, 
and  applications  to  the  pharynx. 

Before  closing  the  subject  of  the  employment  of  the  Eus- 
tachian  catheter  in  aural  disease,  an  allusion  should  at  least  be 
made  to  the  singular  dread  of  the  instrument,  now  happily  dis- 
sipated, which  obtained  in  the  minds  of  the  profession  in  Eng- 
land and  the  United  States.  This  dread  seems  to  have  depended 
upon  two  cases  of  death  from  the  use  of  the  catheter  which 
occurred  in  the  practice  of  Dr.  Turnbull,  then  of  London,  but 
who  occasionally  visited  America,  for  the  purpose  of  treating 
aural  disease,  until  his  death,  which  occurred  a  short  time  since, 
as  I  have  been  informed.  These  famous  cases  were  reported  in 
the  London  Lancet.  In  the  same  journal,2  there  is  a  letter  from 
a  correspondent  accusing  this  Dr.  Turnbull  of  advertising  in  the 

1  A  Practical  Treatise  on  the  Medical  and  Surgical  Uses  of  Electricity,  p.  566. 
5  Vol.  ii.,  1839. 


DEATH  FROM  USE  OF  CATHETER.  409 

Times  in  an  unprofessional  manner — that  is,  by  stating  that  he 
could  cure  ''any  case  of  deafness,  not  arising  from  organic 
disease,  by  the  use  of  a  peculiar  remedy." 

In  order  that  the  length  and  breadth  of  this  matter  of  the 
death  of  patients  from  the  use  of  the  catheter,  may  be  fully 
presented  to  the  profession  and  not  continue  to  be  darkly  hinted 
at,  I  quote  from  the  Lancet1  the  account  of  the  inquest  upon 
these  celebrated  cases. 

On  Monday  evening  an  investigation  took  place  at  the  Carpenters'  Arms, 
Hoxton,  before  Mr.  Baker,  relative  to  the  death  of  Mr.  Win.  Whitbread,  aged 
sixty-six,  which  was  supposed  to  have  been  occasioned  by  an  operation  lately 
performed  on  him  by  Dr.  Turnbull,  of  Eussell  Square.  It  appeared  that  the 
deceased,  who  was  in  the  enjoyment  of  good  health  up  to  that  time,  had  an 
operation  performed  upon  him  on  Thursday  week  by  the  above  physician,  which 
consisted  in  injecting  air  through  the  nostrils  for  the  relief  of  excessive  deaf- 
ness, under  which  he  had  been  for  some  time  laboring.  Almost  immediately 
after  he  was  attacked  with  a  violent  swelling  in  the  throat,  and  though  the 
utmost  attention  had  been  paid  to  him,  he  expired  on  Thursday  last. 

Mr.  Wickham,  a  medical  gentleman  in  the  neighborhood,  deposed,  that  on 
making  a  post-mortem  examination  of  the  body,  he  found  that  the  inflammation 
in  the  throat  was  not  sufficient  to  have  occasioned  the  death  of  the  deceased ; 
death  was  produced  by  extensive  inflammation  of  the  brain,  which,  in  his  opinion, 
was  occasioned  by  natural  causes,  and  that  neither  the  operation  nor  the  inflam- 
mation of  the  throat  had  anything  to  do  with  it. 

The  jury,  on  this  evidence,  returned  a  verdict  of  "  Natural  death  by  the  visi- 
iation  of  God." 

On  Friday  morning,  at  8  o'clock,  an  investigation,  which  occupied  the  greater 
portion  of  the  day,  was  entered  into  before  Mr.  Wakeley,  M.P.,  and  a  highly 
respectable  jury  of  tradesmen,  at  the  Plough  Tavern,  Museum  Street,  to  prose- 
cute the  inquiry  into  the  circumstances  connected  with  the  death  of  Joseph 
Hall,  aged  eighteen,  who  died  while  undergoing  an  operation  for  the  cure  of 
deafness,  at  the  house  of  Dr.  Turnbull,  Eussell  Square,  on  the  morning  of  Sat- 
urday last.  The  circumstances  connected  with  the  case  had  created  an  intense 
interest,  and  during  the  proceedings  the  inquest-room  was  attended  by  many  of 
the  leading  members  of  the  medical  profession. 

George  Kimber  merely  stated  that  he  and  deceased  were  in  the  employ  of 
Mr.  Jackson,  ornamental  composition  maker,  of  Eathbone  Place.  He  saw  him 
last  alive  on  Saturday  morning,  about  7  o'clock,  at  which  time  he  was  get- 
ting ready  to  go  to  Dr.  Turnbull's  to  be  operated  upon  for  deafness,  to  which  he 
was  subject ;  he  was  in  all  other  respects  quite  well  and  healthy. 

Charles  Spadbron,  of  Gravesend,  deposed  that  he  saw  the  deceased  about 
10  o'clock  on  Saturday  morning  at  Eussell  Square.  He  appeared  in  good 
health.  There  were  other  patients  present  at  the  time.  Mr.  Lyon,  the  gentle- 
man who  assists  Dr.  Turnbull,  was  pressed  to  operate.  The  deceased  filled  the 
instrument  himself,  and  discharged  the  air  by  turning  the  cock.  (The  instru- 


1  Vol.  ii.,  p.  558.     1838. 


410  DEATH  FROM  USE  OF  CATHETER. 

merit  was  here  produced,  and  the  witness  showed  how  it  was  filled.  The  bottom 
of  the  cylinder  was  held  fast  between  the  feet,  and  the  piston  worked  up  and 
down  by  the  handle  until  the  pump  became  filled  with  air.)  The  operation  was 
repeated  four  times  on  deceased,  biat  the  tube  through  which  the  air  passed  was 
removed  by  Mr.  Lyon  from  the  right  to  the  left  nostril.  On  the  tube  being 
taken  from  deceased's  nostril  the  fourth  time,  he  fell  back  in  the  chair,  appar- 
ently lifeless,  and  never  spoke  afterward. 

In  answer  to  the  coroner,  the  witness  stated  that  he  had  had  the  operation 
performed  on  himself  four  times  at  a  sitting ;  it  produced  a  swimming  in  the 
head,  and  a  portion  of  the  air  appeared  to  escape  by  the  mouth,  and  the  rest 
down  the  throat. 

Mr.  James  Reid,  of  Bloomsbury  Square,  surgeon,  deposed  to  having,  by 
order  of  the  coroner,  made  a  post-mortem  examination  of  the  body  in  presence 
of  Messrs.  Liston,  Quain,  Savage,  and  Lyon.  Mr.  Reid  went  into  a  long  general 
anatomical  statement,  but  the  only  points  strictly  bearing  on  the  case  were  the 
following :  That  he  found  a  thin  layer  of  blood  on  the  left  side  of  the  membrane, 
and  globules  of  air  under  it,  and  in  the  small  veins  of  the  brain.  That  the  left 
tympanum,  or  internal  ear,  had  its  lining  membrane  swollen,  of  red  appear- 
ance, and  there  was  a  slight  effusion  of  blood  in  it.  From  the  known  plethoric 
habit  of  the  deceased,  and  from  the  fact  of  his  having  exerted  himself  at  filling 
the  air-pump  before  he  was  operated  upon,  he  should  say  the  cause  of  his  death 
was  apoplexy. 

Mr.  Savage,  lecturer  on  anatomy  at  Westminster  Hospital,  was  next  exam- 
ined, and  differed  from  the  last  witness,  and  stated  that  there  was  extravasated 
blood  on  both  sides  of  the  membrane,  and  that  the  tympanum  of  the  right  ear 
was  affected  as  well  as  the  left.  He  did  not  consider  that  deceased  died  of  apo- 
plexy, but  that  the  injection  of  cold  air,  through  the  Eustachian  tubes,  was  the 
primary  cause  of  deceased's  death. 

Mr.  Liston,  surgeon  to  University  College  Hospital,  stated  that  he  was 
present  at  the  post-mortem  examination,  at  the  request  of  the  coroner,  and  the 
probability  was,  that  deceased  died  in  a  continued  fainting  fit.  He  could  not 
easily  disconnect  the  forcible  injection  of  cold  air  into  the  tympanum  from  the 
effect  that  followed  it.  In  the  region  of  the  tympanum  were  a  number  of  small 
nerves,  connected  with  the  most  important  one  in  the  body,  which,  receiving  an 
impression,  would  cause  spasms,  or  other  fatal  affections  of  the  heart.  Nothing 
precisely  satisfactory  could  be  come  to  on  account  of  the  decomposed  state  of 
the  body. 

The  coroner  complained  that  though  the  subject  of  the  inquiry  had  died  on 
Saturday  morning,  no  notice  of  his  death  had  been  sent  by  Dr.  Turnbull  or  Mr. 
Lyon  to  the  summoning  officer  of  the  district.  He  wished  those  gentlemen  to 
give  some  explanation  of  their  conduct. 

Dr.  Turnbull  and  Mr.  Lyon  severally  entered  into  an  explanation. 

The  coroner  then  addressed  the  jury  at  considerable  length.  And  in  accord- 
ance with  the  spirit  of  his  observations,  the  jury  returned  a  verdict  of  "Acci- 
dental death,"  with  a  caution  to  Dr.  Turnbull  never  again  to  entrust  the  instru- 
ment of  operation  in  unprofessional  hands. — (Times.) 

There  are  numerous  explanations  for  these  cases ;  but  the 
account  of  the  post-mortem  is  not  exact  enough  to  allow  us  to 
say  which  of  them  are  correct.  The  first-named  patient  may 


DEATH  FROM  USE  OF  CATHETER.  411 

have  died  from  the  emphysema  produced  by  a  wounding  of  the 
tissue  by  the  point  of  the  instrument.  An  examination  of  the 
tissues  of  the  throat,  immediately  after  the  accident,  would  have 
determined  this  point ;  but  there  is  no  account  of  such  an  exam- 
ination having  been  made.  The  experiments  of  Voltolini '  show 
that  all  traces  of  an  emphysema  would  pass  off  within  ten  hours 
after  death,  so  that  the  post-mortem  examination  would  give  no 
information  on  this  point. 

The  surgeon  who  determined  that  death  was  produced  by  in- 
flammation of  the  brain,  unfortunately  gives  no  account  of  the 
evidences  which  led  to  the  formation  of  this  opinion.  The  second 
patient  may  have  died  in  a  fainting  fit,  or  from  emphysema. 

The  air-pump,  is  now  scarcely  used  in  the  profession  as  a 
means  of  injecting  air  into  the  Eustachian  tubes,  because  the 
air-bag  is  quite  as  efficacious,  and  because  it  is  a  much  simpler 
apparatus.  The  management  of  an  air-press  should  certainly 
never  be  left  to  the  patient. 

Voltolini,  in  the  experiments  to  which  allusion  has  been 
made,  killed  a  rabbit  in  a  few  minutes  by  wounding  the  tissue 
of  the  pharynx,  by  a  wire  passed  through  a  catheter,  and  then 
blowing  forcibly  into  the  opening.  He  thus  produced  great  em- 
physema of  the  neck  and  chest.  Voltolini  believes  that  the 
cause  of  death  of  the  rabbit,  was  a  pressure  upon  the  larynx  by 
the  emphysematous  tissue,  and  not  the  pressure  upon  the  lungs. 
TurnbulPs  patients  may  have  both  died  from  the  same  cause  ; 
but  as  we  do  not  know  the  instrument  used,  or,  in  fact,  any  of 
the  details,  we  can  only  surmise  the  real  cause. 

I  need  hardly  say  that  the  Eustachian  catheter  has  never 
been  even  suspected  of  being  the  cause  of  death,  since  the  time 
of  these  cases,  although  it  is  in  daily  use  by  physicians  in  all 
parts  of  the  civilized  world. 

Before  passing  on  to  a  consideration  of  the  operative  treat- 
ment for  this  class  of  aural  affections,  a  word  or  two  should  be 
said  as  to  the  length  of  time  a  case  should  be  treated.  Inasmuch 
as  we  cannot  hope,  in  many  of  the  cases,  to  do  more  than  arrest 
the  progress  of  disease,  and  perhaps  improve  the  condition,  since 
we  cannot  dismiss  them  as  cured — that  is  to  say,  with  the  hear- 
ing perfectly  restored,  the  tinnitus  aurium  gone — we  desire  to 
know  how  long  we  shall  treat  the  ears  locally.  The  general 
hygienic  treatment,  such  as  the  frequent  employment  of  baths, 
of  a  gargle,  the  exercise  of  great  care  to  keep  the  extremities 
warm,  to  avoid  taking  cold,  and  so  on,  should  be  kept  up  during 


1  Monatsschrift  fiir  Ohrenheilkunde,  Jalirgang  VII.,  No.  1. 


412  DURATION   OF  TREATMENT. 

a  patient's  life,  and  he  should  be  told  at  the  first  consultation, 
that  he  has  a  life-long  warfare  to  engage  in,  unless  he  desires  to 
•end  his  days  with  the  use  of  an  ear-trumpet. 

But  we  cannot  keep  up  a  local  treatment  of  the  Eustachian 
tubes  and  pharynx  indefinitely.  Those  who  believe  that  a  ca- 
tarrhal  pharynx  and  nares  can  be  thoroughly  cured  in  our  cli- 
mate, that  a  disposition  to  colds  in  the  head,  can  be  effectively 
subdued  by  the  use  of  the  spray  of  nitrate  of  silver,  or  the  spray 
of  any  other  agent  used  by  means  of  the  most  perfect  apparatus, 
will  continue  to  use  these  means  of  local  treatment  until  the  end 
is  accomplished.  But  those  who  have  been  less  successful  in 
such  attempts,  must  fix  some  limit  to  the  time  of  treatment.  If 
it  be  proposed  to  get  the  confidence  of  a  patient  suffering  from 
chronic  non-suppurative  middle-ear  disease,  which  is  progres- 
sive in  its  character,  it  is  proper  to  tell  the  whole  truth  a.t  the 
first  consultation  and  say  that  we  have  no  hope  of  making  him 
hear  very  well  again.  It  is  only  a  question  of  arresting  the  pro- 
gress of  the  disease,  and  perhaps  of  increasing  the  hearing 
power.  To  this  end,  about  twice  a  year,  the  patient  should  receive 
a  course  of  local  treatment  until  the  disease  has  ceased  to  pro- 
gress, for  a  period  of  time  varying  from  three  to  eight  weeks, 
while  the  general  treatment  is  to  be  a  life-long  course.  The 
only  reason  that  these  limits  of  time  are  fixed  is,  that  I  have  sel- 
dom seen  anything  accomplished  in  less  than  the  shorter  time, 
or  after  the  longer  term  has  expired.  Very  many  patients  leave 
us,  at  the  outset,  never  to  return.  Some  of  them  cannot  leave 
their  families  to  stay  in  a  large  city  while  their  ears  are  being 
treated.  This  difficulty  is  being  rapidly  met.  In  every  consid- 
erable town  reputable  and  educated  men,  who  have  found  that 
there  is  something  more  in  aural  practice  than  in  syringing  out 
the  wax  and  then  dropping  in  glycerine  to  restore  it,  are  giving 
attention  to  otology,  and  the  laity  are  beginning  to  reap  the 
fruits  of  this  cultivation  of  a  hitherto  barren  field. 

There  is  another  class,  however,  whom  such  advice  never 
influences.  One  of  their  family  has  been  a  victim  of  chronic 
aural  disease  for  a  period  varying  from  two  to  twenty  years, 
and  they  have  at  last,  at  the  request  of  the  family  physician, 
screwed  themselves  up  to  the  courage  of  consulting  a  specialist. 
They  come  in  town  for  a  day's  shopping,  and  call  upon  the  doc- 
tor, meanwhile  always  being  in  a  great  hurry,  and  sending  word 
to  the  consulting-room,  that  they  have  come  fifty  miles  to  see 
him.  When  such  advice  as  I  have  delineated  is  given,  and  the 
almost  bewildered  physician  sits  down  to  lay  out  a  plan  of  treat- 
ment and  correct  the  improper  habits  of  life  that  have  induced 
and  maintained  the  disease,  he  finds  that  he  is  dealing  with  per- 


DURATION    OF   TREATMENT.  413 

sons  who  expect  magic  ear-drops,  vibrators,  or  some  mysterious 
and  quickly  acting  agent  that  will  restore  the  hearing  in  the 
interim  of  rest  of  a  New  York  shopping  excursion.  Of  course, 
such  patients  figure  in  the  statistical  tables  under  the  head  of 
"seen  but  once,  result  unknown,"  although  in  the  mind's  eye 
we  can  set  them  down  as  going  on  slowly  but  surely  to  the  ear- 
trumpet,  and  banishment  from  social  intercourse. 

The  practitioner,  young  or  old,  will  do  much  better  in  such 
cases,  both  for  the  patient,  his  own  reputation,  arid  that  of  the 
profession  in  general,  if  he  decline  to  prescribe  at  all  for  such 
persons,  for  it  is  only  under  favorable  circumstances,  that  is 
to  say,  with  intelligent  patients,  in  easy  circumstances  of  life, 
who  are  attentive  to  advice  and  punctual  in  attendance,  that 
anything  at  all  can  be  accomplished  to  stay  the  progress  of  a 
well-advanced  catarrhal  or  proliferous  process  in  the  middle 
ear. 

Even  then  it  is  not  always  possible.  Certainly  those  who 
have  waited  ten  or  twenty  years,  and  have  finally  consulted  a 
physician  on  account  of  impairment  of  hearing,  depending  upon 
chronic  non-suppurative  inflammation,  with  the  idea  of  getting 
relief  in  one  or  two  or  three  visits,  have  nothing  to  hope  for.  It 
is  better  to  tell  them  so  at  once,  lest  we  unwittingly  emulate  the 
charlatans,  to  whom  all  disease  is  an  object  of  attack  by  medi- 
cation. Otology  has  suffered  much,  from  innocent  attempts  to 
accomplish  that  which  is  in  the  nature  of  things,  not  to  be  ac- 
complished. A  little  frankness  about  chronic  non-suppurative 
disease  of  the  middle  ear,  will  soon  awaken  the  laity  to  the  ne- 
cessity of  attention  to  the  causes  of  the  disease,  and  furnish  us 
all  with  a  larger  proportion  of  curable  cases. 

I  have  found  chronic  catarrhal  cases  much  more  amenable 
to  treatment  than  the  proliferous  form.  Indeed,  I  think  the 
former  cases  are  frequently  curable,  but  the  proliferous  variety 
never.  In  its  results,  in  spite  of  good  local  and  general  care,  it 
is,  to  my  mind,  very  like  progressive  atrophy  of  the  optic  nerve 
or  chronic  glaucoma. 

Since  the  publication  of  the  works  of  the  modern  German 
school  in  this  country,  especially  that  of  Troltsch,  there  has 
been  a  tendency,  in  my  opinion — I  speak  for  myself  at  least — to 
refer  too  many  cases  of  progressive  impairment  of  hearing  to 
catarrhal  or  proliferous  inflammation  of  the  middle  ear,  and  dis- 
eases of  the  nerve  are  ignored,  or  their  existence,  except  as 
secondary  affections,  has  been  even  denied. 

I  advise  the  practitioner,  however,  to  attempt  to  make  a  dif- 
ferential diagnosis  between  disease  of  the  middle  ear  and  of  the 
nerve,  especially  in  cases  of  supposed  chronic  proliferous  in- 


414  DIFFERENTIAL  DIAGNOSIS. 

flammation.  The  means  we  have  at  hand  for  this  purpose,  will 
be  fully  dwelt  upon  when  we  come  to  the  discussion  of  disease 
of  the  nerve.  I  will  only  say  here,  that  the  treatment  of  disease 
of  the  internal  ear,  by  the  local  means  generally  employed  in 
treatment  of  the  middle  ear,  is  harmful,  since  it  aggravates  the 
conditions  by  inducing  congestion  of  the  labyrinth. 


CHAPTER  XV. 

THE  TREATMENT  OF  CHRONIC  NON-SUPPUEATIVE  INFLAM- 
MATION—(  Concluded) . 

Operations  upon  and  through  the  Membrana  Tympani. — History  from  1650  until  our 
own  Day. — Sir  Astley  Cooper's  Cases. — Schwartze's  Statistics. — Politzer's  Eyelet. — 
Tenotomy  of  Tensor-Tympani. — Galvano-cautery. — Division  of  Posterior  Fold. — 
Prout's  Operation. — Hinton's  Removal  of  Accumulations  of  Mucus. — Abandonment 
of  Operations  by  American  Otologists. — Condensed  Air. — Exhaustion  of  Air. — 
Weber-Liel  and  Woakes  on  Paretic  Deafness. — Results  of  Treatment. 

AT  the  time  of  the  publication  of  the  first  editions  of  this  book, 
operations  upon  the  membrana  tympani,  the  ossicles  and  muscles 
of  the  tympanum  were  being  extensively  practised  by  Politzer, 
Weber-Liel,  Hinton,  Orne  Green,  Pomeroy,  and  others,  for  the 
relief  of  chronic  diseases  of  the  middle  ear.  Although  part  of 
the  treatment  thus  pursued  was  avowedly  experimental,  the 
hope  was  pretty  generally  felt  in  the  profession,  that  operative 
procedures  on  and  through  the  drum-head,  might  perhaps  accom- 
plish very  much  in  arresting  the  progress  of  a  disease,  which 
still  remains  incurable  in  a  vast  proportion  of  cases.  I  believe 
that  after  a  fair  trial,  we  are  as  yet  obliged  to  say  that  these 
hopes  have  not  been  realized.  After  a  trial  of  nearly  all  the 
methods  of  operation  of  which  I  have  learned,  I  have  aban- 
doned them,  and  only  in  exceptional  instances  do  I  ever  open 
the  drum-head  by  incisions,  except  in  acute  or  sub-acute  cases. 
It  is  not  because  the  operations  are  dangerous,  that  I  have  aban- 
doned them.  That  I  have  not  found.  But  it  is  because  they  do 
nothing  to  stop  tinnitus  aurium,  or  arrest  progressive  impairment 
•of  hearing  in  chronic  non-suppurative  inflammation.  It  may  be 
asked,  Why,  then,  consider  the  subject  fully  in  a  practical  trea- 
tise ?  To  this,  I  answer,  that  it  is  one  of  great  historical  interest. 
for  the  work  that  has  been  done  in  this  direction  has  been  by 
the  ablest  of  otologists,  and  has  at  least  taught  us  much  of  the 
prognosis  and  nature  of  chronic  non-suppurative  inflammation. 
Besides,  much  useless  experimentation  on  the  part  of  younger 
observers  will  be  avoided,  if  they  have  easy  access  to  what  has 
been  already  done.  There  is,  therefore,  a  justification  for  a  full 


416  PERFORATION   OF   MEMBRAXA   TYMPANI. 

consideration  of  this  subject,  such  as  I  shall  endeavor  to  give  in 
this  chapter. 

The  reader  of  otological  literature  will  be  almost  appalled  by 
the  amount  of  material  on  this  subject.  It  begins  with  Chesel- 
den's  experiments  on  the  drum-heads  of  dogs,  and  ends  as  yet, 
with  Weber's  operation  upon  the  tensor-tympani  muscle,  and 
Politzers  section  of  the  posterior  fold  of  the  membrana  tympani. 
From  the  mass  of  authorities  I  have  collected  a  history  of  this 
subject. 

I  am  indebted  to  Schwartze's  brochure '  for  much  of  the  his- 
torical sketch  from  the  time  of  Riolanus  up  to  1845,  although  I 
have  greatly  amplified  his  references  to  Sir  Astley  Cooper's  writ- 
ings, as  well  as  to  those  of  other  English  authorities,  and  by  no 
means,  as  one  reviewer  assumed,  have  I  merely  given  a  transla- 
tion of  Schwartze's  interesting  paper. 

Johannes  Riolanus  (1650),  of  Paris,  about  150  years  before 
the  time  of  Sir  Astley  Cooper,  who  is  usually  supposed  to  be  the 
originator  of  the  operation  of  perforation  of  the  membrana  tym- 
pani, inquired  if  it  would  not  be  possible  to  improve  the  hearing 
of  the  deaf,  by  destroying  the  membrana  tympani.  He  was  led 
to  make  this  inquiry  from  the  fact  that  he  knew  of  a  deaf  per- 
son, whose  hearing  was  restored  by  an  accidental  rupture  of  the 
membrana  tympani,  by  means  of  an  ear-spoon. 

It  is  well  to  remember  that,  until  very  recently,  there  were 
no  exact  measures  taken  to  estimate  the  amount  of  hearing, 
and  that,  consequently,  such  phrases  as  "the  hearing  was  re- 
stored," "the  hearing  became  perfect,"  as  they  occur  in  ancient 
books,  only  mean  that  the  hearing  was  improved,  sometimes 
very  much,  sometimes  very  little. 

About  a  hundred  years  later  (1722),  T.  Cheselden,  surgeon  to 
St.  Thomas'  Hospital,  London,  well  known  as  the  inventor  of 
the  operation  for  artificial  pupil,  actually  operated  upon  dogs, 
and  I  quote  from  his  work  on  anatomy "  the  description  of  his 
cases.  Speaking  of  the  membrana  tympani,  he  says  :  "I  found 
it  once  half  open  on  a  man  that  I  dissected,  who  had  not  been 
deaf,  and  I  have  seen  a  man  smoke  a  whole  pipe  of  tobacco  out 
through  his  ears,  which  must  go  from  the  mouth,  through  the 
Eustachian  tube,  and  through  the  tympanum,  yet  this  man 
heard  perfectly  well.  These  cases  occasioned  me  to  break  the 
tympanum  in  both  ears  of  a  dog,  and  it  did  not  destroy  his  hear- 
ing, but  for  some  time  he  received  strong  sounds  with  great 
horror." 

1  Studien  und  Beobachtungen  uber  die  Kiinstliche  Perforation  des  Trommelfells,  Ar- 
chiv  fur  Ohrenheilkunde,  Bd.  II.,  S.  24  . 

4  The  Anatomy  of  the  Human  Body,  p.  250.    London,  1732. 


PERFORATION   OF   MEMBRANA  TYMPANI.  417 

Cheselden  then  goes  on  to  say  that  an  anatomist  named  St. 
Andre  assured  him  that  "a  patient  of  his  had  the  tympanum 
destroyed  by  an  ulcer,  and  the  auditory  bones  came  out  with- 
out destroying  the  hearing."  I  have  only  been  able  to  obtain 
the  second  edition  of  Cheselden's  works,  but  Schwartze  quotes 
from  the  seventh,  where  the  author  states  that  he  obtained  per- 
mission to  perform  this  operation,  that  was  then  esteemed  such 
a  formidable  one,  upon  a  prisoner.  If  the  prisoner  survived  the 
operation,  he  was  to  have  his  freedom.  Unfortunately  for  sci- 
ence and  for  the  criminal,  the  proposed  subject  became  ill, 
so  that  the  operation  was  indefinitely  postponed.  Sir  Astley 
Cooper '  says  that  such  an  outcry  was  aroused  by  the  inhuman- 
ity of  the  proposed  operation,  that  Cheselden  never  again  ob- 
tained permission  to  perform  it. 

Dienert  (1748),  of  Paris,  in  a  dissertation,  recommended  per- 
foration of  the  membrana  tympani  for  the  purpose  of  evacuating 
blood  or  pus  from  the  cavity  of  the  tympanum.  Itard  says  that 
Julius  Busson  proposed  the  operation  six  years  before  this. 

The  first  man  who  actually  performed  the  operation  as  a 
means  of  benefiting  the  hearing,  was  a  person  named  Eli  (1760)," 
who  seems  to  have  been  a  charlatan. 

Portal  and  Sabatier,  two  Paris  surgeons,  who  lived  at  the 
same  time  as  Eli,  knew  nothing  of  his  operations.  Portal  pro- 
posed to  puncture  the  membrana  tympani,  in  the  cases  where  it 
was  greatly  thickened.  Sabatier,  on  the  other  hand,  proposed 
to  perform  the  operation  upon  a  relaxed  membrana  tympani. 

Wilde  quotes  a  passage3  from  Dr.  Peter  Degravers,  of 
Edinburgh,  who  lived  in  1788,  and  who  styled  himself  Pro- 
fessor of  Anatomy  and  Physiology,  which  shows  that  he  had 
performed  the  operation.  Degravers  says  :  "I  incised  the  mem- 
brana tympani  of  the  right  ear  with  a  sharp,  long,  but  small 
lancet.  I  left  the  patient  in  that  state  for  some  time,  and  after- 
ward observed  that  it  had  united.  I  incised  again  the  mem- 
brana tympani  of  the  right  ear,  but  crucially,  and,  on  removing 
some  of  the  parts  of  the  membrane  incised,  I  discovered  some 
of  the  ossicula,  which  I  brought  out."  Schwartze  naively  re- 
marks, "  There  is  no  account  of  the  results  in  this  case." 

In  the  beginning  of  this  century,   at  about  the  same  time 

1  Philosophical  Transactions,  p.  152.    1800. 

2  The  following  paragraph  is  quoted  by  Gairal,  Lincke's  Sammlung,  Bel.  V.,  p.  109, 
in  proof  of  Eli's  operation:   "EstLutetirc  homo  quidam  ELI  dictus,  qui  surditatem 
curare  audet,  dummodo  malum  nona  paralysi  nervi  septimi  paris  oriater,  en  vero  eins 
methodum  tympanum  exscindit  et  suppositum  inimittit.     Feci  experirnenta  qusedam, 
quae  satis  bene  ipsi  cessarunt." 

3  Aural  Surgery,  English  edition,  p.  15. 

27 

* 


418  SIR  ASTLEY    COOPER'S   CASES. 

{1800),  and  independently  of  each  other,  Dr.  Karl  Himly,  then 
of  Brunswick,  Germany,  and  Sir  Astley  Cooper,  proposed  the 
operation,  especially  in  closure  of  the  Eustachian  tube.  Himly 
had  demonstrated  to  his  students,  in  1797,  by  experiments  upon 
the  human  cadaver  and  living  dogs,  that  the  operation  could  be 
easily  and  safely  performed  ;  but  he  did  not  perform  it  on  the 
living  subject  until  180G.  He  reports  a  brilliant  result  in  one 
case  only,  in  a  person  suffering  from  syphilitic  ulcers  of  the 
pharynx,  who  had  been  deaf  for  years  from  closure  of  the  Eus- 
tachian tube. 

After  Sir  Everard  Home  had  published  his  paper  on  the 
functions  of  the  membrana  tympani,  a  paper  to  which  allusion 
has  already  been  made  in  this  volume,  Sir  Astley  Cooper  pub- 
lished a  careful  and  exact  account '  of  the  case  of  a  medical 
student  at  St.  Thomas'  Hospital,  in  London,  who  had  lost  his 
membrana  tympani,  but  who,  nevertheless,  could  hear  quite  well. 

The  student  was  twenty  years  of  age,  and  applied  to  Sir 
Astley  in  the  winter  of  1797.  He  was  attacked  at  ten  years  of 
age  with  suppuration  in  the  left  ear,  and  in  about  twelve  months 
after  with  the  same  disease  in  the  other  ear.  There  was  a  pro- 
fuse discharge  for  weeks  from  both  ears,  and  in  the  discharge 
bones,  or  pieces  of  bones,  were  observable.  The  patient  was 
totally  deaf  for  three  months  ;  the  hearing  then  began  to  return, 
and  in  about  ten  months  from  the  last  attack  it  was  restored  to 
the  state  in  which  it  was  when  he  consulted  the  great  English 
surgeon.  Sir  Astley  then  gives  an  account  of  the  means  by 
which  he  decided  that  the  drum-heads  were  perforated.  The 
patient  having  filled  his  mouth  with  air,  he  closed  his  nostrils- 
and  contracted  his  cheeks  ;  the  air  thus  compressed  was  heard 
to  rush  through  the  meatus  auditorius  with  a  whistling  noise, 
and  'the  hair  hanging  from  the  temples  became  agitated  by  the 
current  of  air  which  issued  from  his  ear.  "To  determine  this 
with  greater  precision,  I  called  for  a  lighted  candle,  which  was 
applied  in  turn  to  each  ear,  and  the  flame  was  agitated  in  a  sim- 
ilar manner."  '  The  examination  of  the  case  was  continued  in 
this  thorough  manner. 

The  gentleman,  when  in  company,  was  capable  of  hearing 
what  was  said  in  the  usual  tone  of  conversation,  and  he  could 
hear  with  the  ear  in  which  there  was  no  trace  of  a  membrana 
tympani,  better  than  with  the  one  in  which  there  was  merely  a 
circular  opening.  When  a  note  was  struck  upon  the  piano,  he 
could  hear  it  but  two-thirds  of  the  distance  at  which  the  ex- 
aminer could  hear  it. 

1  Philosophical  Transactions,  loc.  cit. 


PERFORATION   OF   MEMBRANA  TYMPANI.  419 

Although  this  case  was  accessible  to  the  profession  from  the 
year  1800,  it  is  surprising  to  find  the  belief  still  widely  prevalent 
among  the  laity  and  the  profession,  that  the  destruction  of  the 
membrana  tympani  involves  almost  complete  loss  of  hearing. 
The  advance  in  the  simplicity  of  means  of  an  accurate  diagnosis 
in  aural  disease,  is  nowhere  more  distinctly  seen  than  in  a  com- 
parison of  Cooper's  method  of  determining  whether  the  mem- 
brana tympani  be  intact  or  injured,  with  that  of  the  surgeon  of 
the  present  day,  who  with  no  aid  from  the  patient,  but  with  the 
otoscope,  is  able  to  state  just  what  the  condition  of  the  part  is, 
and  in  a  very  brief  space  of  time. 

This  observation  led  the  way  to  the  operation  of  perforation 
of  the  membrana  tympani1  for  the  relief  of  impaired  hearing. 
The  only  indication  that  the  great  English  surgeon  spoke  of  was 
closure  of  the  Eustachian  tube,  which  he  believed  arose  from  the 
following  causes  : 

1.  A  common  cold  affecting  the  parts  contiguous  to  the  ori-' 
fices  of  the  tube,  and  thereby  preventing  the  free  passage  of  air 
into  the  tympanum. 

2.  Ulcers  in  the  throat,  from  the  scarlet  fever,  which  in  heal- 
ing frequently  close  the  Eustachian  tubes. 

3.  A  venereal  ulcer  in  the  fauces,  by  the  cicatrix  it  produces, 
may  cause  a  closure  of  the  tube. 

4.  An  extravasation  of  blood  in  the  cavity  of  the  tympanum. 
The  scientific  character  of  Astley's  observations  is  nowhere 

better  shown  than  in  these  indications,  which  are  exact,  and  in 
consideration  of  the  state  of  knowledge  as  to  the  means  of  open- 
ing the  Eustachian  tube,  correct.  The  last-named  condition  is 
the  only  one  that  may  be  said  to  be  incorrect.  The  tympanic 
cavity  might  be  full  of  blood  without  causing  closure  of  the  Eus- 
tachian tube. 

Sir  Astley  reports  four  cases  : 

CASE  I. — A  woman,  thirty -six  years  old,  who  had  been  affected  for  eight 
years.  The  deafness  arose  from  enlargement  of  the  tonsil  glands ;  a  puncture 
of  the  drum-head  was  made,  and  while  she  stayed  in  the  consulting-room  for  one- 
half  hour,  she  could  hear  ordinary  conversation. 

CASE  II. — Ann  D ,  age  not  stated,  so  deaf  as  not  to  hear  words  unless 

spoken  close  to  the  ear.  She  had  been  affected  for  six  weeks.  She  could  hear 
a  watch  when  pressed  upon  her  ear.  After  the  puncture  she  could  hear  the 
watch  several  feet. 

CASE  III. — J.  E ,  aged  seventeen.     The  hearing  had  been  impaired  since 

1  Sir  Astley's  paper  descriptive  of  liis  operations  was  read  June  21,  1801.  See 
Philosophical  Transactions  of  the  Royal  Society  of  London,  1801. 


420  SIE   ASTLEY   COOPER'S   CASES- 

birth.  There  was  an  imperfect  state  of  the  fauces,  so  that  he  could  not  blow  his 
nose.  The  Eustachian  tubes  had  no  openings  into  his  throat.  Puncture  of  the 
membrana  tympani  produced  such  a  confusion  that  he  nearly  fainted,  but  in  two 
minutes  he  recovered,  and,  two  months  after,  his  hearing  continued  perfect. 

CASE  IV. — A  person  was  sent  to  Sir  Astley,  who  had  received  a  blow  upon  the 
head,  which  had  occasioned  symptoms  of  concussion  of  the  brain,  and  was  attended 
•with  a  discharge  of  blood  from  each  ear.  He  recovered  from  all  the  effects  of 
the  blow  but  the  deafness.  Blood  was  found  in  the  atiditory  canal.  After  clear- 
ing this  away  and  perceiving  no  benefit,  suspecting  that  a  quantity  of  blood  was 
lodged  in  the  tympanum,  in  a  few  days  he  punctured  the  membrana  tvmpani. 
Blood  mingled  with  the  wax  was  discharged  for  ten  days,  during  which  time  the 
hearing  was  gradually  restored. 

This  case  was  undoubtedly  one  of  fracture  of  the  temporal 
bone  through  the  tympanic  cavity,  such  as  have  been  reported 
by  Buck  and  Rushmore.  They  have  been  fully  described  in  the 
tenth  chapter. 

In  closing  his  paper,  Sir  Astley  states  that  little  pain  is  felt  in 
the  operation,  and  that  no  dangerous  consequences  follow.'  The 
Valsalvian  experiment  was  the  means  by  which  he  determined 
whether  the  Eustachian  passage  was  open  or  not,  for  he  says 
that,  when  the  experiment  succeeds,  the  tube  is  open.  Besides 
this,  the  patient  should  be  able  to  hear  a  watch  placed  between 
the  teeth  or  on  the  temporal  bones.  Cooper  published  his  four 
cases  of  good  results,  and.  according  to  Schwartze  and  Frank, 
he  was  soon  inundated  by  deaf  persons  from  all  parts  of  Europe. 
He  then  operated  on  fifty  more  cases,  but  the  results  were  either 
slight,  null,  or  they  lasted  for  a  short  time  only.  Cooper  then 
declined  to  see  deaf  patients,  on  account  of  the  fact  that  he  was 
doing  very  little  good,  and  also  because  his  fame  as  a  surgeon 
was  suffering  from  his  reputation  as  an  aurist.  After  the  lapse 
of  more  than  seventy  years,  the  dispassionate,  scientific  char- 
acter of  Sir  Astley  Cooper's  writings  on  this  subject,  stands  in 
striking  contrast  to  the  charlatanism  of  some  of  those  who  fol- 
lowed him  in  this  operation. 

After  Cooper's  operations,  a  great  interest  was  excited  in 
France  on  this  subject,  and,  according  to  the  medical  journals  of 
the  time,  quoted  by  Schwartze,  Riber  of  Bordeaux,  Maunoir  of 
Geneva,  and  others,  operated,  but  with  no  permanent  results. 

In  Germany,  also,  the  same  interest  was  created.  Michaelis, 
a  professor  in  Marburg,  informs  his  friend  Hunold,  of  Capel, 

1  Sir  William  Wilde  states  that,  within  a  few  months  of  his  death,  Sir  Astley  ex- 
hibited the  greatest  interest  in  this  subject,  and  left  his  consulting-room  full  of  patients 
for  a  long  time,  to  send  for  a  man  in  Bond  Street,  upon  whom  he  had  operated,  in 
order  to  exhibit  him  to  Mr.  Wilde. —  Vide  Dublin  Journal,  vol.  xxv.,  1844. 


PERFORATION   OF   MEMBRANA   TYMPANI.  421 

that  he  had  operated  on  one  case  successfully.  Hunold  then 
proceeded  to  puncture  every  membrana  tympani  to  which  he 
could  get  access.  Finally,  Hunold  records  that  he  has  had  the 
brilliant  result  of  curing  or  improving  seventy  cases  out  of  a 
hundred.  Subsequently,  it  was  shown  by  others,  that  these 
results  were  not  only  exaggerated,  but,  that  they  were  not  even 
at  all  in  accordance  with  truth.  Of  Michaelis'  63  cases,  in  42 
there  was  no  result  whatever;  while  in  21,  or  one-third,  there 
was  greater  or  less  improvement.  But,  of  all  these,  in  only 
one  was  there  a  permanent  result  six  years  after ;  perhaps  the 
benefit  was  permanent  in  three  other  cases. 

Schwartze  says  that  after  Hunold's  marvellous  accounts  of 
his  successful  results  from  perforation  of  the  membrana  tym- 
pani, the  operation  became  the  fashion,  and  every  one,  who  did 
not  have  the  finest  hearing,  allowed  the  drum-heads  of  the  ear 
to  be  pierced.  Even  the  poor  deaf-mutes  had  their  drum  mem- 
branes perforated.  Fashions  in  medicine  are  not  confined  to  our 
own  time. 

To  stem  this  tide  of  charlatanism,  Karl  Himly,  professor  in 
Gottingen,  wrote  a  commentary  upon  the  operation,  and  showed 
that  it  was  only  in  exceptional  cases  that  it  was  of  any  value. 
These  exceptional  cases  were  such  as  those  reported  by  Cooper, 
for  the  relief  of  which,  since  there  were  no  means  of  opening  the 
Eustachian  tube,  paracentesis  of  the  membrana  tympani  was  a 
beneficial  operation ;  but  the  profession  seem  not  to  have  studied 
Sir  Astley  Cooper's  cases,  but  it  was  merely  known  that  he  per- 
forated the  membrana  tympani  with  benefit  to  the  hearing. 
Himly's  paper  excited  so  much  attention  that  the  operation  was 
not  heard  of  for  a  long  time. 

In  England,  as  we  have  seen,  Cooper  abandoned  the  operation 
and  otological  practice.  Stimulated  by  the  opportunity  for  enter- 
ing an  operative  field,  Saunders  opened  an  aural  clinic  in  1804, 
but  soon  closed  it  on  account  of  the  poor  results  of  treatment. 
He  speaks  of  one  case  of  perforation  in  which  a  good  result  was 
obtained.  After  him  came  Curtis,  who  talks  of  the  operation  in 
vtry  general  terms,  but  without  furnishing  cases.  Buchanan 
also  promised  to  describe  his  cases,  but  he  never  did  ;  and 
Schwartze  thinks  that  Degravers,  the  Edinburgh  professor, 
from  whom  I  have  quoted,  and  Stevenson,  are  not  to  be  relied 
upon. 

In  France,  Itard,  Boyer.  and  Deleau  wrote  upon  this  subject. 
Itard  was  wise  enough  to  perforate  a  drum  membrane  of  a  deaf- 
mute  whose  tympanic  cavity  was  filled  with  masses  of  tenacious 
mucus,  and  he  succeeded  in  removing  them  after  the  operation 
by  syringing.  This  was  an  anticipation  of  Mr.  James  Hinton's 


422  PERFORATION   OF   MEMBRAISTA   TYMPANI. 

operation.  In  170  other  cases,  there  was  absolutely  no  result. 
He  calls  attention  to  the  fact  that  permanent  suppuration  may 
occur  even  when  the  operation  is  very  carefully  performed. 

Saissy  (1822),  of  Lyons,  in  his  work  on  the  ear,  speaks  guard- 
edly of  the  operation,  and  of  only  one  case  where  the  result  was 
entirely  satisfactory.  Dr.  Nathan  K.  Smith,  of  Baltimore,  trans- 
lated Saissy's  book,  and  invented  an  instrument  for  perforation 
of  the  drum-head,  which  he  described  in  the  appendix  to  his 
translation  ;  but  there  is  no  account  of  the  success  of  the  opera- 
tion in  this  country. 

Schwartze  gives  very  little  credence  to  Deleau's  account 
of  his  successful  results.  He  claims  to  have  improved  eigh- 
teen out  of  twenty-five  deaf  persons  and  deaf-mutes,  by  the 
operation. 

Hendriksz,  of  the  University  of  Groningen,  in  1828,  in  an 
inaugural  thesis  on  the  subject,  which  Schwartze  used  in  his 
historical  sketch,  states  that  in  the  institutions  for  the  deaf  and 
dumb,  in  Berlin,  Vienna,  and  Groningen,  this  operation  was  fre- 
quently performed.  In  Groningen,  81  deaf-mutes  were  operated 
upon,  of  whom  17  received  for  the  moment  a  more  or  less  decided 
improvement.  We  hear  nothing  then  of  the  operation  for  twenty 
years,  until  Hubert  Yalleroux,  in  1843,  wrote  an  essay  upon  the 
danger  attending  it.  He  speaks  of  two  cases  of  death  from  it. 

Wilde,1  in  defence  of  the  operation,  when  performed  under 
proper  indications,  says  that  Dr.  Butcher,  of  Dublin,  reported  two 
cases  with  a  view  of  showing  the  ill-consequences  resulting  from 
the  performance  of  the  operation,  and  relates  the  cases  of  two 
young  persons,  a  woman  and  a  man,  in  both  of  whom  it  would 
appear  that  death  ensued  from  puncturing  the  membrane.  In 
the  first  instance,  the  only  history  of  the  case  is  that,  prior  to 
this  period,  she  got  a  severe  cold,  with  a  swelling  of  the  glands 
of  the  neck.  No  account  is  given  of  the  cause  or  origin  of  her 
deafness,  the  condition  of  the  membrana  tympani,  why  the 
operation  was  performed,  in  what  manner,  by  whom,  or  with 
what  instrument.  According  to  Wilde,  all  that  we  know  is, 
that  "catheterism  of  the  Eustachian  tube  was  performed,  aftd 
said  to  fail ;  hence  it  was  agreed  that  the  membrane  of  the  tym- 
panum should  be  pierced,  a  small  piece  being  drilled  out  of  the 
membrane  of  the  right  side."  No  exact  account  of  the  operation 
and  no  names  of  the  witnesses  are  given.  Inflammation  ensued, 
and  four  months  after  she  died,  when  the  petrous  bone  was  found 
roughened  and  softened,  and  the  membrana  tympani  entirely 
destroyed.  This  case,  certainly,  with  such  a  history,  can  form 


1  Text-book,  English  edition,  p.  297. 


PERFOEATION   OF   MEMBRANA   TYMPANI.  423 

no  text  for  a  homily  against  paracentesis  of  the  drum  mem- 
brane. 

The  second  case  is  equally  indefinite.  Wilde  says  all  that  is 
known  of  the  case  is,  that  he  applied  to  a  surgeon  and  had  his 
tympanum  pierced,  "but  why,  or  whether  with  a  gimlet  or  a 
punch,  a  trocar  or  a  probe,  we  are  not  informed.  At  first  the 
hearing  improved,  and  then  relapsed.  After  some  time  head- 
symptoms  set  in,  and  the  man  died  in  six  weeks."  On  the  post- 
mortem examination,  the  brain  and  its  membranes  were  found 
in  an  inflamed  condition,  and  a  small  abscess  in  the  anterior 
lobe  of  the  brain,  on  the  same  side  upon  which  the  puncture  was 
made.  The  cause  of  the  deafness  in  this  case  was  found  to  be 
a  small  tumor,  about,  the  size  of  a  bean,  lying  on  the  acoustic 
nerve. 

Paracentesis  of  the  membrana  tympani  was  certainly  not  in- 
dicated in  this  case,  and  the  two  together  form  no  more  of  an 
argument  against  the  operation,  than  the  indefinitely  reported 
cases  of  death  from  the  use  of  the  Eustachian  catheter  do  against 
the  use  of  that  instrument. 

The  treatises  on  diseases  of  the  ear,  of  Kramer,  Rau,  Bonna- 
f ont,  Toynbee,  and  the  earlier  editions  of  Troltsch,  add  very  little 
to  our  knowledge  of  this  subject. 

It  has  thus  been  seen,  that  the  first  indication  which  was  set 
down  by  the  old  authors,  was  closure  of  the  Eustachian  tube. 

Sir  Astley  was  incorrect  in  his  ideas  as  to  the  closure  of  the 
tube  being  the  cause  of  the  conditions  for  which  he  opened  the 
drum-head,  but  his  operation  was  a  proper  one  for  those  condi- 
tions, so  far  as  we  can  understand  his  cases.  For  example,  the 
perforation  of  the  drum-head  for  the  evacuation  of  blood  was  a 
proper  procedure.  Again,,  in  the  case  of  the  woman  who  had 
been  deaf  for  six  weeks,  the  operation  was  undoubtedly  of  ser- 
vice, even  if  of  only  temporary  value.  Closure  of  the  Eusta- 
chian tube  no  longer  exists  in  the  minds  of  the  profession  as  an 
independent  affection,  except  in  extremely  rare  cases.  When 
its  action  is  impeded,  the  congestion  or  swelling  of  its  lining 
is  always  associated  with  similar  conditions  in  the  tympanic 
cavity. 

Since  the  scientific  use  of  catheters  and  bougies,  it  is  no 
longer  recognized  as  a  correct  indication  for  perforation  of  the 
drum-head.  In  the  very  rare  cases  in  which  there  is  an  imper- 
meable stricture  from  cicatrization,  it  would  be  a  proper  opera- 
tion. 

Thickening  of  the  membrana  tympani  was  another  promi- 
nent indication  of  the  old  authors — not  of  Cooper,  however.  We 
now  know  that  a  thickening  of  this  .membrane  that  is  confined 


424  SCHWARTZE' s  CASES. 

to  the  outer  layers,  may  be  removed  by  appropriate  local  appli- 
cations, while  one  that  has  extended  to  the  fibrous,  or  mucous 
layer,  or  both,  is  nearly  always  accompanied  by  thickening  of 
the  whole  lining  membrane  of  the  cavity  of  the  tympanum,  so 
that  this  indication  may  also  be  dismissed. 

A  collection  of  blood,  pus,  or  mucus,  in  the  cavity  of  the 
tympanum,  is,  then,  the  only  indication  of  the  old  writers  which 
may  fairly  be  said  to  be  up  to  the  present  standard  of  knowl- 
edge. The  collections  are  readily  diagnosticated  in  all  acute 
and  sub-acute  cases,  and  still  remain  good  indications  for  per- 
foration of  the  membrana  tympani. 

From  this  chaos  of  illy  defined  indications  and  imitative  ex- 
periment, there  came  out  one  fact  in  proper  form.  That  one 
fact  was  this  :  That  it  was  pre-eminently  proper  to  perforate  the 
membrana  tympani  in  order  to  remove  mucus,  blood,  or  pus, 
which  could  not  find  an  exit  through  the  Eustachian  tube.  Sir 
Astley  Cooper's  favorable  cases  showed  this  fact.  Itard's  deaf- 
mute  was  also  another  illustration  of  its  truth  ;  but,  throughout 
all  the  history  of  these  cases,  we  do  not  find,  until  we  come 
down  to  Saunders,'  and  later  to  Hermann  Schwartze.  of  Halle, 
that  one  writer  had  been  able  to  select  this  single  grain  of  wheat 
from  the  chaff.  Schwartze  saw  what  had  been  shown  by  the 
cases  that  were  published,  and  in  his  first  article J  revived  the 
operation  of  paracentesis,  but  chiefly  applied  it  to  acute  disease, 
where  these  accumulations  of  mucus,  blood,  or  pus  are  likely  to 
occur.  The  operation  is  now  well  established  as  a  means  of 
treatment  in  acute  cases,  and  has  already  been  described  in  the 
chapter  on  "Acute  Catarrh  of  the  .Middle  Ear." 

Schwartze  published  a  few  years  since,  100  cases  of  chronic 
aural  catarrh,  in  which  he  has  performed  a  paracentesis  of  the 
membrana  tympani.  Before  passing  on  to  review  the  methods  of 
writers  who,  since  Schwartze's  paper  was  published,  have  modi- 
fied the  simple  operation  and  enlarged  its  field,  so  as  to  cause  it 
to  play  a  great  part,  as  they  claim,  in  curing  chronic  cases  of 
catarrhal  and  proliferous  inflammation,  I  will  venture  to  criti- 
cise Schwartze's  table  of  results.  Of  his  100  cases,  only  2  were 
in  persons  over  fifty  years  of  age.  Between  forty  and  fifty 
there  were  3  persons,  between  thirty  and  forty  8,  and  only  17 
were  over  twenty.  The  remaining  81  were  under  that  age,  and 
46  were  between  one  and  ten  years,  and  35  between  ten  and 
twenty.  In  America,  cases  of  chronic  non-suppurative  inflam- 
mation occurring  in  young  persons  are  usually  quite  tractable 

1  See  Introductory  Chapter,  p.  27. 

9  Archiv  fur  Ohrenheilkunde,  Bd.  II.,  p.  36. 


SCHWARTZE   ON   PARACENTESIS.  425 

without  paracentesis.  We  are  chiefly  anxious  to  enlarge  our 
therapeutic  means  for  the  cases  of  persons  who  are  more  than 
sixteen  years  of  age,  and  especially  for  those  who  are  adults  in 
middle  life.  Again,  in  34  of  the  cases,  the  disease,  whatever  it 
was,  had  not  existed  for  a  year.  There  were  only  10  cases  where 
the  aural  affection  had  lasted  between  five  and  ten  years,  and 
in  6  cases  only,  more  than  ten  years. ' 

Schwartze,  in  a  review  of  this  work,  seems  to  think  that  I  have  clone  him 
injustice  in  these  remarks,  as  well  as  in 'the  sentence  where  I  stated  that  "I 
have  been  in  the  habit  of  treating  many  of  the  cases  that  he  treats  by  paracen- 
tesis, by  simpler  means."  He  advises  me  to  study  the  indications  that  he  has 
laid  down,  a  little  more  exactly.  I  have  again  gone  over  this  subject  from 
Schwartze's  writings,  and  I  am  still  of  the  opinion  that  many  of  his  one  hundred 
cases  are  not  entitled  to  a  place  among  cases  of  chronic  catarrh,  as  generally  un- 
derstood, and  I  also  think  that  very  many  of  them  were  curable  without  para- 
centesis, and  that  scarcely  any  American  or  English  surgeon  would  deem  this 
operation  necessary  for  such  cases. 

In  saying  this,  I  am  not  aware  of  making  any  rude  criticism  upon  Schwartze's 
procedures.  Certainly,  I  have  never  intended  to  be  discourteous.  But,  as  a 
teacher  of  otology,  I  am  bound  to  speak  freely  and  frankly  of  any  course  of 
treatment  publicly  promulgated,  even  if  it  come  from  as  high  an  authority  as 
that  of  Professor  Schwartze. 

Schwartze's  cases  show  that  valuable  as  is  paracentesis  of 
the  membra.na  tympani,  in  accumulations  of  mucus  in  the  tym- 
panum and  in  cases  of  catarrh  of  comparatively  recent  origin, 
we  have  not  found  in  it,  a  remedy  for  old  and  neglected  cases 
of  catarrhal  and  proliferous  inflammation.  Schwartze's  con- 
tributions, in  other  words,  principally  affect  acute  and  sub- 
acute  disease,  or  exacerbations  in  chronic  affections.  The  line 
should  have  been  a  little  more  distinctly  drawn  between  the 
cases  of  sub-acute  and  chronic  inflammation,  for  which  para- 
centesis was  performed.  In  other  words,  Schwartze  has  failed, 
in  my  opinion,  to  prove  by  his  statistics,  that  paracentesis  is  of 
any  particular  value  in  chronic  cases.  That  it  is  an  important 
means  of  treatment  for  acute  and  sub-acute  cases,  he  proved, 
and  thus  revived  a  valuable  operation. 

It  was  thought  by  many  (1845)  that,  if  a  permanent  opening 
could  be  kept  in  a  drum-head,  the  great  desideratum  would  be 
attained.  Bougies  were  placed  in  an  opening  made  writh  a  small 
trephine,  and,  when  it  was  found  that  this  excited  too  much  re- 
action, a  gold  tube,  three  lines  long,  and  having  a  little  ridge  on 
both  ends,  was  inserted,  with  a  view  of  keeping  up  a  permanent 


1  Archiv  fiir  Ohrenheilkuiide,  Bd.  VI.,  p.  195. 


426  POLITZER' s  EYELET. 

opening.1  This  was  years  before  Politzer  introduced  his  eyelet. 
In  1868,  Politzer  had  a  case  in  which  he  placed  an  eyelet  in  a 
cicatrix  which  he  had  incised.  Although  of  service  in  this  case, 
it  has  proved,  however,  to  be  beneficial  only  in  very  exceptional 
cases,  where,  perhaps,  repeated  paracentesis  would  do  quite  as- 
well.  Several  cases  of  accident  have  occurred  in  its  use.  I  saw 
one  case  in  which  the  opening  had  closed  and  left  the  foreign 
body  in  the  cavity  of  the  tympanum.  I  saw  the  case  but  once. 
Dr.  Noyes "  reported  another  case,  where,  in  attempting  to  in- 
sert the  eyelet,  it  was  lodged,  not  in  the  membrana  tympani, 
but  in  the  cavity  of  the  tympanum.  Eighteen  days  after,  at  the 
patient's  solicitation,  he  was  placed  under  chloroform  and  the 
eyelet  removed  by  making  quite  an  opening  in  the  membrana 
tympani.  The  suppuration  from  this  opening  ceased,  and  the 
opening  closed  in  sixteen  days.  The  hearing  distance  was  im- 
proved, from  contact  with  the  meatus,  to  three  and  one-half 
inches  while  there  was  an  opening  in  the  membrane  ;  when  the 
opening  closed,  the  hearing  went  back  to  the  first-named  point. 
This  accident  of  escape  of  the  eyelet  into  the  tympanum  is  thus 
one  quite  likely  to  happen,  either  at  the  time  the  membrane  is 
pierced,  or  subsequently.  The  suppuration  which  occurs  is  more 
apt,  however,  to  force  the  membrane  into  the  tympanum  than 
into  the  canal. 

The  published  experience  of  those  who  have  performed  this 
operation  does  not  commend  it  as  a  successful  procedure,  and  I 
believe  that  it  is  now  very  seldom  performed. 

Wreden  (1867),'  of  St.  Petersburg,  went  far  beyond  the  prop- 
ositions to  make  an  opening  in  the  membrana  tympani.  and 
excised  a  portion  of  the  handle  of  the  malleus. .  Inasmuch  as  the 
chief  vascular  supply  of  the  membrana  tympani  was  along  the 
handle  of  the  malleus,  Wreden  believed,  and  with  correctness, 
that,  by  cutting  this  off,  there  would  be  less  probability  that  the 
opening  would  close.  He  says  that,  when  he  removed  two- 
thirds  of  the  membrana  tympani  and  the  handle  of  the  malleus, 
he  never  saw  the  opening  fully  heal.  This  operation  never 
found  much  favor,  for  the  reason  that  it  proved  to  be  dangerous 
to  the  hearing  and  even  to  the  life  of  the  patient.  It  often  ex- 
cited an  otitis  suppurativa  of  so  severe  a  form,  as  to  destroy  the 
remainder  of  the  hearing  power.  It  may  be  doubted,  too,  judg- 
ing from  analogous  cases  occurring  accidentally,  whether  even 
such  an  opening  would  not  heal.  The  regenerative  power  of.  the 

1  Frank's  Practische  Anleitung,  p.  310.    Erlangen,  1845. 

*  Transactions  of  the  American  Otological  Society,  third  year,  p.  57. 

1  Monatsschrift  fiir  Ohrenheilkunde,  Bd.  I. 


INCISION   WITH   GALVANO-CAUTERY.  427 

membrana  tympani  is  indeed  marvellous.  We  need,  however, 
spend  very  little  time  over  this  operation,  for  it  has  been  prac- 
tically abandoned  by  the  imitators  of  Wreden,  if  not  by  the  dis- 
tinguished author  himself. 

Voltolini,1  following  the  suggestion  of  Erhard,  made  the 
incision  with  the  galvano-cautery,  in  the  hope  that  the  open- 
ing made  in  this  way  would  be  longer  in  closing.  He  made  an 
incision  through  the  centre  of  the  posterior  section  of  the  mem- 
brane. There  was  a  crackling  sound,  as  if  one  passed  a  knife 
through  a  tense  paper.  This  first  operation  was  011  a  patient 
who  had  been  deaf  for  three  years,  and  had  suffered  from  fever, 
after  which  he  became  blind  from  cataract  and  deaf  from  un- 
known causes,  or  at  least  unstated  ones.  Immediately  after  the 
deafness  appeared,  which  is  stated  to  have  been  complete,  he 
was  treated  by  the  Eustachian  catheter,  but  without  effect. 

Voltolini's  first  operation  did  not  result  in  much  if  any  bene- 
fit to  the  patient,  but  it  proved  that  an  opening  made  by  the 
galvano-caustic  apparatus  could  be  kept  open  longer  than  one 
made  by  the  knife.  Voltolini  improved  the  hearing  of  a  patient 
in  whose  membrane  he  had  made  an  opening  with  the  galvano- 
cautery  to  such  an  extent,  that  a  watch  which  was  not  heard 
before  the  operation,  except  when  laid  upon  the  auricle,  was- 
heard  more  than  an  inch,  and  ordinary  conversation  so  well 
that  the  patient,  who  was  a  shop-keeper,  was  able  to  carry  on 
his  business.  The  tinnitus  aurium  and  sensations  of  pressure 
in  the  head  were  also  removed. 

Gruber's  (18G3)  operation,  which  he  calls  "myringodecto- 
my,"  consists  in  forming  a  flap  in  the  membrana  tympani  by 
means  of  a  knife  and  forceps.  The  flap  is  cut  off.  Voltolini 
shows  that  this  operation  is  both  difficult  and  dangerous.  It  is 
difficult  on  account  of  the  surgeon  being  obliged  to  work  with 
two  instruments  in  a  narrow  canal.  That  it  is  dangerous  is 
shown  by  the  histories  of  the  cases  which  Gruber  gives,  e.g.,  one 
patient  had  fever  from  the  9th  to  the  21st  of  November;  and 
quite  severe  hemorrhage  during  and  after  the  operation,  so  that 
the  auditory  canal  was  several  times  filled  with  blood.  Volto- 
lini also  calls  attention  to  the  fact,  that  Gruber's  method  is  but 
a  modification  of  the  old  operations  with  perforators  :  but  we 
may  say,  that  all  these  operations  are  modifications  of  old  ideas 
and  suggestions.  In  one  of  Gruber's  cases  the  opening  still  ex- 
isted five  months  after  the  operation  was  performed. 

F.  E.  Weber  (1868),  of  Berlin,2  recommended  the  division  of 


1  Monatsschrift  fur  Ohrenheilkunde,  Bd.  I. ,  p.  39. 
3  Ibid.,  Jahrgang  II.,  p.  51. 


428  DIVISION   OF  TENSOR  TYMPANI. 

the  tensor  tympani  muscle,  and  the  "abnormal  adhesions  that 
may  occur  in  the  region  of  this  muscle."  One  of  the  chief  indi- 
cations is  the  relief  of  pressure  upon  the  labyrinth  from  retrac- 
tion of  the  tensor  tympani.  This  muscle  has  its  origin  from  the 
cartilaginous  portion  of  the  Eustachian  tube,  and  runs  along 
the  edge  of  the  bony  canal,  and  is  inserted  by  a  well-defined 
tendon  on  the  inner  angle  and  inner  surface  of  the  handle  of  the 
malleus. 

Weber  thus  advanced  far  beyond  the  idea  of  maintaining  a 
permanent  opening  in  the  membrane,  and  carried  into  effect  an 
old  idea  of  dividing  abnormal  adhesions  that  may  form  between 
the  ossicula.1 

Dr.  Weber  published  an  article  in  January,  1872,  in  which 
he  goes  very  fully  into  the  object,  effect,  and  manner  of  per- 
forming his  operation.  It  is  well  known  that  the  great  Vienna 
anatomist,  Hyrtl,  was  the  first  to  suggest  this  operation,  but 
Weber  was  the  first  to  perform  it.  At  the  time  of  the  publica- 
tion of  Weber's  last  article  he  had  operated  upon  about  fifty 
cases. 

There  were  two  conclusions  which  led  Weber  to  the  per- 
formance of  this  operation  :  1st,  The  fact  that  had  been  demon- 
strated that  the  tensor  tympani  muscle  kept  not  only  the  mem- 
brana  tympani  and  the  ossicula  with  their  ligaments,  but  also 
the  labyrinth,  by  means  of  the  stapes,  in  a  state  of  tension,  and 
that,  consequently,  an  increased  tension  or  rigidity  of  the  mus- 
cle prevented  the  proper  conduction  of  sound  and  increased  the 
pressure  upon  the  labyrinth.  3d,  He  also  reasoned  that  this 
increased  tension  would  of  itself  excite  and  maintain  catarrhal 
inflammation  of  the  tympanic  cavity,  especially  if  there  was  at 
the  same  time  an  affection  of  the  tube,  and  that  it  might  cause 
a  hindrance  to  the  circulation  in  the  labyrinth,  with  tinnitus 
aurium,  etc.  In  short.  Dr.  Weber  thought  it  possible  that  many 
varieties  of  non-suppurative  affections  of  the  middle  ear  might 
depend  upon  excessive  contraction  of  this  muscle. 

The  tenotomy  is-  divided  into  four  stages  : 

1.  The   membrana   tympani   is  perforated   with   the   hook- 
shaped  extremity  of  the  tenotome,  about  1  to  1£  mm.  in  front  of 
the  handle  of  the  malleus,  somewhat  below  and  to  one  side  of 
the  short  process. 

2.  The  hook-shaped  knife  is  pushed  forward  into  the  cavity 
of  the  tympanum — the  handle  of  the  instrument  being  brought 
downward  and  forward — and  thus  it  is  made  to  grasp  the  ten- 
•don.    (Just  how  the  operator  is  to  know  when  the  hook  is  around 

~  * 

1  Loc.  cit.,  Jabrgang  IV.,  p.  143. 


DIVISION   OF   TENSOR  TYMPANI.  429 

• 

the  tendon,  I  am  unable  to  learn  from  Dr.  Weber's  description. 
I  suppose,  however,  from  previous  familiarity  with  the  opera- 
tion on  the  cadaver.) 

3.  While  the  hook  is  about  or  over  the  tendon,  the  operator 
exerts  a  gentle,  drawing  pressure  upon  it,  by  turning  the  handle 
of  the  tenotome  toward  the  face  of  the  patient ;  the  hook  is  then 
turned  a  third  upon  its  axis,  by  means  of  the  button  which  acts 
upon  the  cog,  and  the  tendon  is  cut.    A  distinct  crackling  sound 
is  heard  at  the  moment  of  the  division  of  the  tendon. 

4.  The  hook  is  then  brought  away  from  its  position  by  re- 
versing the  action  of  the  button  which  acts  on  the  cog,  and  the 
instrument  is  withdrawn. 

Dr.  Weber  at  a.  later  date  gives  the  results  of  his  operation 
in  nine  rather  ponderous  formulas,  but  they  may  be  summed  up 
in  the  statement  that  it  is  claimed  that  the  operation,  in  most 
cases  for  which  it  is  properly  performed,  diminishes  tinnitus 
aurium,  vertigo,  prevents  many  persons  from  becoming  abso- 
lutely deaf,  and  that,  if  a  permanent  result  is  desired,  fluid  must 
afterward  be  regularly  forced  into  the  cavity  of  the  tympanum, 
by  means  of  a  Weber's  pharmaco-koniantron. 

Weber  has  reported  cases  which  confirm  his  view  of  the 
benefit  from  the  division  of  the  tensor  tympani.  It  will  be  seen 
by  reading  these  cases,  that  he  follows  up  the  operation  by*  the 
'most  decided  treatment  of  the  middle  ear,  thus  placing  this 
operation  where,  I  believe,  all  perforations  of  the  membrana 
tympani  should  be  placed,  as  one  of  the  means  of  assisting  in 
the  thorough  medication  of  the  middle  ear  by  injections  of  fluid 
and  air.  Although  there  is  usually  a  temporary  effect  from  the 
letting  up  of  the  intra-auricular  pressure,  it  cannot  be  compared 
to  such  an  operation  as  iridectomy  for  glaucoma,  when  the  use 
of  the  knife  ends  the  treatment. 

Gruber  also  advocated  the  division  of  the  tensor  tympani 
muscle,  on  account  of  the  fact  demonstrated  by  Helmholz,  that 
this  muscle  moves  the  whole  chain  of  the  ossicula  auditus,  as 
well  as  the  malleus,  inward,  a  fact  which  causes  us  to  believe 
that  the  intra-auricular  pressure  must  be  increased  and  morbid 
changes  caused  by  any  excessive  contraction  of  this  muscle. 
Gruber  calls  attention  to  the  fact  which  he  was  the  first  to  show, 
as  he  claims,  that  the  muscle  is  inserted  not  only  on  the  inner 
angle,  but  also  on  the  anterior  surface  of  the  handle  of  the  mal- 
leus, and  he  also  alludes  to  what  we  have  already  noticed  in  the 
chapter  on  the  anatomy  of  the  middle  ear,  that  the  tensor  tym- 
pani is  intimately  connected  or  united  to  the  tensor  palati  mus- 
cle.  This  seems  to  indicate  that  the  frequent  affections  of  the 
soft  palate  must  have  some  abnormal  influence  upon  the  tensor 


430  DIVISION   OF  TENSOR   TYMPANI. 

tympani.  Gruber  considers  the  indications  for  a  division  of  the 
tensor  tympani  to  be  a  retraction  or  contraction — a  shortening 
of  this  muscle.  These  indications  may  be  known  by  studying 
the  changes  on  the  folds  or  pockets  of  the  membrana  tympani. 

"If  the  membrane  is  drawn  very  much  inward,  and  the  lower 
end  of  the  malleus  goes  with  it,  while  the  upper  retains  its  posi- 
tion, and  thus  the  posterior  fold  becomes  more  prominent,  we 
.have  an  indication  of  the  abnormal  sunken  position  of  the  drum- 
head." '  Gruber  admits  that  this  sinking  of  the  drum-head  may 
depend  upon  other  causes  than  the  retraction  of  the  tensor  tym- 
pani ;  but  these  may  be  readily  distinguished.  The  excessive 
contraction  of  the  muscle  causes  the  handle  of  the  malleus  to 
appear  broader,  and  the  membrana  tympani  to  look  as  if  twisted, 
in  a  state  of  what  in  surgical  language  is  called  torsion.  The 
.anterior  ligament  of  the  malleus,  which  passes  from  the  spina 
tympanica  to  the  neck  of  the  malleus,  also  becomes  more  prom- 
inent, in  retraction  of  the  tendon  of  the  tensor  tympani.  The 
final  mark  of  retraction  of  the  muscle,  according  to  Gruber,  is 
the  more  or  less  rapid  reposition  of  the  membrane  in  its  former 
position  after  the  air-douche  has  been  employed.  It  is  certainly 
very  easy  for  us  to  verify  these  indications,  as  given  by  Gruber, 
and  it  is  to  be  hoped  that  the  operation  will  have  a  fair  trial  in 
the  "class  of  cases  of  non-suppurative  disease,  for  which  we  have 
as  yet  done  so  little. 

Gruber  advises  that  the  tendon  be  usually  divided  as  Weber 
recommends,  in  front  of  the  handle  of  the  malleus.  The  acci- 
dent that  may  possibly  happen,  if  the  membrane  is  opened  pos- 
teriorly to  the  malleus,  according  to  Gruber,  is  a  perforation  of 
the  carotid  artery,  if  the  carotid  canal  be  incomplete  in  its  bony 
wall ;  but  this  kind  of  an  accident  seems  to  be  almost  impossible, 
with  any  care  in  the  management  of  the  tenotome.  As  another 
argument  for  the  anterior  incision,  it  is  stated,  that  the  laby- 
rinth cannot  be  entered  if  the  opening  be  made  in  front  of  the 
malleus,  while  the  knife  might  possibly  go  through  the  foramen 
ovalis,  if  the  opening  be  made  posteriorly.  Gruber  uses  a  much 
simpler  instrument  than  Weber's  for  the  division  of  the  tendon. 
It  is  a  narrow,  needle-like  knife,  fastened  in  a  handle  at  an  ob- 
tuse angle.  The  knife  is  three  inches  long,  and  has  a  blade 
cutting  only  on  the  anterior  edge.  This  cutting  edge  is  ground 
to  a  point,  and  curved  to  such  an  extent  that,  when  the  instru- 
ment is  passed  one-half  a  millimetre  in  front  of  the  malleus, 
through  the  membrana  tympani,  the  shaft  of  the  needle  stands 

1  Seperat-abdruck  .aus  der  Allgemeinen  Wiener  Medizinischen  Zeitung,  January,^ 
1872. 


DIVISION   OF   TENSOR  TYMPANI.  431 

parallel  to  the  long  axis  of  the  auditory  canal.  The  point  of  the 
knife  reaches  only  a  little  above  the  inner  margin  of  the  handle 
of  the  malleus,  but  does  not  pass  far  beyond  the  posterior  seg- 
ment of  the  membrana  tympani. 

The  pain  from  the  operation  of  division  of  the  tensor  tympani 
is  not  usually  very  great,  and  it  is  seldom  necessary  to  etherize 
a  patient  for  the  purpose  of  performing  it.  Gruber  performs  the 
operation  in  cases  of  what  he  terms  hypertrophic  or  plastic  in- 
flammation of  the  middle  ear  (proliferous  inflammation),  where 
the  ordinary  treatment  has  failed  to  benefit  the  case.  The  head 
of  the  patient  is  held  by  an  assistant,  the  drum-head  well  illumi- 
nated, and  the  tenotome  is  passed  through  the  anterior  segment 
of  the  membrane,  and  by  turning  the  outer  end  of  the  knife  to- 
ward the  face  of  the  patient,  the  point  is  pushed  around  the 
handle  of  the  malleus  to  the  other  segment  of  the  drum-head. 
The  incision  is  then  elongated  about  three  millimetres,  while  the 
knife  is  held  in  the  same  position,  and  then  withdrawn.  There  is 
•considerable  resistance  in  the  tissue  when  the  tendon  is  divided, 
and  a  crackling  sound  is  heard.  The  hemorrhage  from  the 
operation  is  usually  very  slight.  The  air-douche,  by  the  catheter 
or  Politzer's  method,  should  be  used  after  the  cutting  is  finished, 
and  the  ear  closed  lightly  with  cotton,  while  the  patient  should 
be  kept  quietly  in  the  house  and  avoid  taking  cold. 

Those  who  doubt  whether  it  is  possible  to  divide  the  tendon 
without  also  cutting  other  parts,  will  have  their  doubts  removed 
by  performing  the  operation  on  the  dead  body  according  to  the 
directions  of  Weber  or  Gruber,  and  then  making  an  examination 
of  the  parts. 

Dr.  Orne  Green  recommends  that  Gruber's  operation  be  done 
"by  making  the  incision  posterior  to  the  handle  of  the  malleus, 
and  with  a  little  broader  knife.1 

Hartmann  uses  a  small  knife  curved  on  the  flat  and  on  the 
edge,  for  division  of  the  tensor  tympani.  The  point  of  the  knife 
reaches  about  1  mm.  further  outward  than  its  upper  edge.  Hart- 
mann first  makes  an  incision  into  the  posterior  segment  of  the 
membrane  about  1  mm.  behind  the  handle  of  the  malleus,  and 
learns  what  changes  occur  in  the  hearing  distance  and  in  the 
tinnitus  aurium.  The  tenotome  is  then  introduced  into  the  tym- 
panic cavity  for  a  distance  of  3  mm.,  whereby  the  knife  is  placed 
below  the  tendon  of  the  tensor  tympani  between  the  handle  of 
the  malleus  and  the  long  crus  of  the  incus.  By  slightly  sinking 
its  handle  the  sharp  point  of  the  tenotome  is  forced  so  far  to- 

1  Dr.  Green  has  some  preparations  made  by  himself  in  Wedl's  laboratory  in  Vienna, 
in  which  the  fact  that  the  tendon  is  exactly  and  cleanly  divided  in  his  operation,  is 
-clearly  shown. 


432  DIVISION   OF   POSTERIOR  FOLD. 

ward  the  upper  part  of  the  tympanic  cavity,  that  the  tendon  is 
obliquely  divided  on  the  withdrawal  of  the  instrument.1 

Lucae  (1871)  divided  the  posterior  pocket  or  fold  of  the  mem- 
brana  tympani,  in  what  he  terms  "dry  catarrh  of  the  middle 
ear "  (proliferous  inflammation),  where  there  is  a  marked  sink- 
ing inward  of  the  handle  of  the  malleus,  and  great  prominence 
of  the  short  process,  and  when  the  Eustachian  tube  is  perme- 
able.2 Lucae  uses  a  bayonet-shaped  needle,  and  the  incision  is 
made  from  below  upward,  in  order  to  avoid  cutting  the  chorda 
tympani.  If  this  nerve  be  divided,  it  is  probably  not  a  serious 
accident,  judging  from  cases  of  injury  to  the  drum-head  in 
which  the  chorda  tympani  has  been  injured.  Of  109  cases  oper- 
ated upon  by  this  method,  Lucae  claims  to  have  greatly  bene- 
fited 40,  and  to  have  improved  39,  while  in  24  there  was  no 
benefit  from  the  operation. 

A  question  of  priority  has  arisen  between  Dr.  Lucae  and 
Professor  Politzer,  in  regard  to  the  performance  of  this  opera- 
tion, but  I  will  not  venture  to  discuss  this  subject. 

Politzer  performs  the  same  operation,  in  order  to  render  the 
membrane  more  movable,  under  the  name  of  the  incision  of  the 
posterior  fold  of  the  membrana  tympani.  The  incision  is  a 
longitudinal  one,  at  right  angles  to  the  long  axis  of  the  fold, 
between  the  short  process  of  the  malleus  and  the  peripheric  end 
of  the  fold.3 

Voltolini  (1870)  advised  the  use  of  a  probe,  which  is  intro- 
duced daily  in  an  opening  made  by  the  galvanic  cautery,  for 
some  weeks  after.  I  am  not  able  to  say  whether  Voltolini  has 
found  this  method  a  certain  means  of  maintaining  an  opening, 
but  I  am  inclined  to  think  not,  from  the  fact  that  so  little  is 
heard  from  him  on  the  subject. 

Dr.  Prout  (1872)  divides  adhesions  between  the  membrana 
tympani  and  the  promontory  with  a  very  small  iridectomy-knife, 
having  a  long  handle.  His  principle  of  operation  is,  to  divide 
the  adhesions  according  to  their  situation.  I  have  seen  him 
perform  the  operation  in  two  cases. 

In  the  first  case*  the  membrana  tympani  was  very  much 
sunken,  and  an  adhesion  to  the  promontory  had  occurred,  as 
shown  by  an  opaque,  yellow,  immovable  spot  on  the  correspond- 

1  Politzer:  Text-book.     Translation,  p.  383. 

2  Seperat-abdruck  aus  der  Berliner  Klinischen  Wochenschrift,  No.  4.     1872. 

3  Translation  of  Politzer's  Lecture,  by  Dr.  Burnett.     Philadelphia  Medical  Times, 
vol.  ii.,  No.  56. 

4  Myringodectomy,  followed  by  a  decided  improvement  in  the  hearing  power,  in  a 
case  of  adhesion  between  the  membrana  tympani  and  the  promontory.     Transactions 
of  the  Medical  Society  of  the  State  of  New  York,  1872. 


PROUT'S  OPERATION.  433 

ing  point  of  the  membrane.     In  performing  the  operation,  Dr. 

Prout  used  a  knife  such  as  is  here  represented. 

The  patient  was  thirty -three  years  of  age,  a  teacher  by  occu- 
pation,  and  had  been  treated  by  Dr.  Prout  for  some  time 
u  previous  to  the  operation,  for  advancing  non-suppura- 
tive  inflammation  of  the  middle  ear,  but  in  spite  of  the 
use  of  the  catheter,  Politzer's  method,  and  of  the  poste- 
rior nares  syringe,  the  patient  continued  to  grow  steadily 
worse  as  to  her  hearing,  and  the  tinnitus  aurium  became 
so  unbearable  as  almost  to  unfit  her  for  her  daily 
duties. 

On  October  3,  1871,  the  patient  was  placed  under  the 
influence  of  ether,  and  Dr.  Prout  having  illuminated 
the  ear  by  means  of  the  otoscope  upon  a  forehead  band, 
entered  the  knife  in  front  of  the  adhesion,  and  cut 
around  the  promontory,  with  which  the  end  of  the  han- 
dle of  the  malleus  was  in  contact.  By  means  of  "  a  little 
cutting,  picking,  and  teasing,  a  free  opening  was  made 
of  about  one  and  one-half  lines  in  diameter."  An  at- 
tempt was  made  to  remove  the  piece  of  membrane  ad- 
herent to  the  promontory ;  but  the  operator  was  not 
certain  that  he  succeeded.  As  soon  as  the  patient  re- 
covered from  the  ether,  she  said  that  she  heard  better. 
The  warm  douche  was  used  to  quiet  the  pain,  which 
was  not  severe,  however.  The  hearing  power  for  the 
voice  was  much  improved  by  the  operation.  The  patie'nt 
was  able  to  hear  reading  and  conversation  at  thirty  feet 
in  front  of  her,  while  before  she  could  on  one  side  only, 
and  then  at  ten  feet.  There  was  a  slight  purulent  dis- 
charge for  about  a  week  after  the  operation  ;  but  no 
very  severe  pain.  One  year  after  the  operation  the 
opening  in  the  membrana  remained  of  the  original  size  ; 
the  cavity  of  the  tympanum  was  dry ;  the  watch  was 
heard  when  pressed  upon  the  auricle — before  the  opera- 
tion it  was  not  heard  at  all — ordinary  conversation  was 
readily  heard  at  the  distance  of  twenty  feet. 

Dr.  Prout  thus  succeeded  in  maintaining  what  may 

— Prout's    fairly  be  called  a  permanent  opening  in  the  drum-head, 
and  in  giving  great  relief  to  the  patient  for  a  time.     A 

permanent  suppurative  inflammation  resulted  from  the  second 

case. 

Mr.  Hinton  (1869) '  believed  that  mucus  dried  up  and  became 

1  On  Mucous  Accumulations  within  the  Cavity  of  the  Tympanum.    From  the  Guy's 
Hospital  Reports,  1869. 
28 


434  HINTON   ON  ACCUMULATION   OF   MUCUS. 

dense  in  the  cavity  of  the  tympanum,  and  thus  became  a  cause 
of  "confirmed  deafness."  He  therefore  made  an  incision  into  the 
membrana  tympani  in  order  to  remove  this  hardened  mucus. 

Mr.  Hinton's  operation  consists  of  an  incision  in  the  mem- 
brana tympani,  through  which  fluid  is  injected  into  the  cavity 
of  the  tympanum  and  Eustachian  tube.  The  incision  is  made 
with  a  lance-shaped  knife,  in  the  inferior  and  posterior  quadrant 
of  the  drum-head,  and  is  from  two  to  three  or  even  more  lines  in 
length.  The  syringing  is  done  with  some  force,  in  order  to  drive 
out  of  the  cavity,  into  the  Eustachian  tube  and  pharynx,  dried 
or  inspissated  mucus,  the  collection  of  which,  in  many  cases, 
according  to  both  pathological  and  clinical  experience,  is  the 
cause  of  the  impairment  of  hearing  and  the  tinnitus.  I  have 
seen  Mr.  Hinton  perform  this  operation,  and  two  cases  upon 
which  it  had  been  performed  some  time  before.  In  both  these 
cases  the  patients  were  confident  that  there  was  an  improvement 
in  the  hearing,  and  a  lessening  of  the  disturbing  symptoms  for 
some  months  after  the  operation. 

The  process  of  washing  out  the  cavity  of  the  tympanum, 
upon  which  Mr.  Hinton  lays  great  stress,  is  done  by  means  of  a 
syringe  fitting  hermetically  into  the  external  meatus.  A  solu- 
tion of  bicarbonate  of  soda  is  used.  The  syringing,  which  I  did 
on  one  occasion  at  Mr.  Hinton's  clinic  at  Guy's  Hospital,  Lon- 
don, immediately  after  Mr.  Hinton  had  performed  the  operation, 
sometimes  causes  vertigo,  which  passes  away  in  a  few  moments. 

Mr.  Hinton  once  divided  the  chorda  tympani  nerve  in  per- 
forming the  operation  of  incision  of  the  membrane.  "  The  patient 
felt  a  sudden  shock  running  down  the  tongue,  the  corresponding 
side  of  which  suffered  an  impairment  alike  of  general  and  of 
special  sensibility  in  its  whole  extent.  The  patient  began  to 
recover  in  two  or  three  days."  The  most  frequent  ill  effect  is  an 
inflammation  of  the  external  auditory  canal ;  when  this  is  appre- 
hended the  ear  should  be  syringed  through  the  Eustachian  tube 
instead  of  the  meatus. 

Mr.  Hinton  performed  his  operation  in  sub -acute  or  quite 
recent  cases  of  accumulation  of  mucus  in  the  cavity  of  the  tym- 
panum, as  well  as  in  those  of  long  standing,  such  as  have  formed 
the  subject  of  discussion  in  the  preceding  chapters.  I  confess  to 
a  little  skepticism,  however,  as  to  the  fact  of  inspissated  mucus 
being  the  sole  cause  of  the  impairmant  of  hearing  in  many  of  the 
chronic  cases.  The  post-mortem  examinations  of  ears,  whose 
function  was  much  impaired  for  a  long  time,  that  have  as  yet 
been  made,  do  not  reveal  this  as  the  only  lesion  in  many  cases. 

Since  the  above  was  published,  I  have  largely  added  to  my 
experience  in  operations  upon  the  membrana  tympani,  and  I 


VIEWS   OF   AMERICAN   OTOLOGISTS.  435 

have  also  had  the  opportunity  of  studying  some  of  the  cases  of 
other  surgeons  as  if  they  were  my  own.  As  a  result  of  this  ex- 
perience, as  I  have  said  at  the  opening  of  this  chapter,  I  have 
given  up  all  operations  upon  the  drum  membrane  or  upon  the 
tendon  of  the  tensor  tympani,  in  chronic  non-suppurative  cases, 
when  there  is  no  suspicion  of  retained  mucus  in  the  tympanic 
cavity.  I  believe  that  any  operations  yet  suggested,  are  inade- 
quate to  relieve  tinnitus  aurium,  improve  the  hearing,  or  even 
to  retard  the  advance  of  this  form  of  disease.  I  read  a  paper ' 
expressing  this  opinion  before  the  American  Otological  Society 
in  J881,  and  my  views  were  confirmed  by  the  members  who  took 
part  in  the  discussion,  by  Blake,  Buck,  Kipp,  Noyes,  Burnett, 
Bartlett,  Mathewson,  Theobald,  as  representing  "  as  well  as  any 
one  statement  could  reflect  the  varied  opinions  of  those  who 
were  interested  in  otological  questions  "  (Buck).  It  may  be  said 
then,  that  a  majority  of  the  authorities  on  the  treatment  of  aural 
disease  in  the  United  States,  have  up  to  this  time,  given  up  these 
operations  in  chronic  non-suppurative  cases,  where  there  is  no 
suspicion  of  fluid  in  the  tympanic  cavity.  If  we  can  yet  find  a 
safe  means  of  making  a  permanent  opening  in  the  membrana 
tympani,  I  believe  we  should  benefit  quite  a  large  class  of  cases, 
as  yet  unalleviated  by  any  means.  As  Politzer2  points  out,  this 
permanent  opening  can  only  be  useful,  "when  the  stapes  is  still 
movable,  when  the  membrane  of  the  fenestra  rotunda  is  not 
thickened  or  calcified,  and  when  no  labyrinthine  complications 
exist."  I  believe  that  we  shall  yet  find  some  means  of  securing 
a  permanent  opening  in  the  membrana  tympani,  for  we  some- 
times see  cases  where  we  find  it  impossible  to  close  an  opening 
made  by  suppuration.  The  application  of  collodion  (McKeown) 
and  paper  disks  (Blake)  have  been  advised  for  relaxation  of  the 
drum-head.  I  have  tried  the  disks,  but  as  yet  without  good 
results. 

In  the  choice  of  an  instrument  for  a  simple  paracentesis,  it 
seems  to  me  too  much  has  been  said.  For  Weber's  operation, 
Gruber's  knife  seems  to  me  the  best,  and  for  Prout's  operation 
peculiar  instruments  are  required,  which  will  vary  according  to 
the  situation  of  the  adhesions,  their  size,  and  so  on  ;  but  for  the 
ordinary  paracentesis,  whether  we  require  a  long  or  short  in- 
cision, a  puncture  or  a  flap,  an  ordinary  cataract-needle  will  do 
very  well.  Those  who  prefer  an  angular  instrument  will  find 
Blake's  knife,  that  which  is  attached  to  his  modification  of 
Wilde's  polypus  snare  (which  should  be  lengthened  in  the  shank, 
however),  one  of  the  best.  The  use  of  an  anaesthetic  is  not  at 

1  Transactions,  vol.  ii.,  p.  458.  *  Text-book,  p.  373. 


436  INSTRUMENTS   FOR   PARACENTESIS. 

all  necessary,  except  where  adhesions  are  to  be  divided,  and  the 
dissection  is  to  be  therefore  prolonged.  Some  of  the  German 
authors  find  the  membrana  tympani  very  sensitive,  even  under 
chloroform ;  but  from  what  I  have  seen  of  the  use  of  chloroform 
on  the  Continent,  I  think  many  of  the  operators  are  so  fearful  of 
the  results  of  the  anaesthetic,  that  they  do  not  put  their  patients 
fairly  to  sleep.  If  ether  be  used  as  we  use  it  in  this  country,  the 
drum-head  may  be  readily  made  insensible.  I  usually  perform 
paracentesis  without  ether,  and  often  in  my  consulting-room.  I 
do  not  regard  it  as  a  serious  or  painful  operation.  The  patient's 
head  should  have  a  good  rest,  and  the  otoscope  be  used  on  a 
forehead  band,  so  that  both  hands  may  be  free.  In  ordinary 
perforations  for  the  purpose  of  washing  out  the  cavity,  the  pos- 
terior and  inferior  quadrant  is,  perhaps,  the  best  position  for  the- 
incision. 

On  page  287  will  be  found  a  representation  of  the  paracen- 
tesis needle  which  I  generally  use. 

Some  of  the  instruments  formerly  recommended  for  perforation  of  the  mem- 
brana tympani,  were  probably  never  actually  used — such  as  one  very  like  a. 
cork  screw,  and  a  red-hot  trochar.  Cooper  employed  a  small  trochar  in  a  canula, 
the  point  of  the  trochar  projecting  at  the  most,  one  and  a  half  lines.  Since  the 
rigid  canula'would  be  apt  to  hurt  the  membrana  tympani,  upon  which  it  was 
pressed  before  the  trochar  was  pushed  forward,  Saissy  used  a  canula  of  elastic 
wood,  which  caused  no  pain.  Itard  punctured  the  membrane  with  a  blunt 
probe.  Eicheraud  recommended  that  the  opening  be  maintained  by  the  sub- 
sequent use  of  the  pure  nitrate  of  silver,  in  solid  form  ;  but  I  have  found  the 
use  of  this  caustic  one  of  the  most  effectual  means  of  closing  an  opening  from 
an  old  suppurative  process.1 

Since  the  above  was  written,  Dr.  Sexton  and  Dr.  C.  H.  Bur- 
nett have  revived  the  operations  upon  the  drum-head  and  os- 
sicles, especially  the  operation  for  the  removal  of  the  latter 
for  the  relief  of  the  tinnitus  and  impairment  of  hearing  in 
chronic  non-suppurative  inflammations.  Dr.  Sexton  has  read 
several  papers  upon  the  subject,  but  the  profession  as  yet  re- 
mains unconvinced,  I  think,  as  to  the  results  of  this  procedure 
in  such  subjects.  Further  experience,  and  the  details  of  a  fair 
number  of  cases  in  which  good  results  have  been  obtained,  are 
necessary  before  the  judgment  founded  upon  the  failure  of  our 
best  men,  with  the  same  class  of  cases,  and  with  the  same 
operation,  is  required,  before  removal  of  the  ossicles  is  generally 
adopted  as  a  therapeutic  resource.  In  Sexton's  earlier  papers  he 

1  The  most  complete  account  of  tjie  instruments  used  or  recommended  for  perfora- 
tion of  the  membrana  tympani  by  various  authorities,  is  found  in  Beck's  Krankheiten 
des  Gehororganes,  p.  45.  Heidelberg  and  Leipzig,  1827. 


THE   EFFECTS   OF   CONDENSED   AIR.  437 

advocates  removal  of  all  the  ossicles,  but  to  judge  from  his 
latest  reports,  published  in  the  Archives  of  Otology  for  May,  1891, 
he  removes  only  the  malleus.  '  The  incus  and  stapes  he  now 
admits  are  not  always  visible.  The  membrana  tympani  is  also 
removed.  This  is  very  apt  to  re-form,  when  the  hearing  does  not 
continue  to  be  as  much  improved.  I  advise  a  careful  considera- 
tion of  Lucae's '  cases,  as  well  as  the  isolated  cases  of  Prout  and 
Hackley,  referred  to  in  this  volume,  before  too  high  hopes  are 
had  as  to  the  efficacy  of  this  operation  in  any  considerable  class 
of  cases.  But  it  is  a  sound  surgical  procedure,  in  chronic  suppu- 
rations, as  a  means  of  removing  necrosed  bones  and  hopelessly 
morbid  tissue.  But  this  is  no  new  discovery,  and  has  no  bear- 
ing upon  the  present  subject. 

THE  EFFECTS  OF  CONDENSED  AIR  UPON  THE  HEARING  POWER. 

From  some  peculiar,  but  unexplainable  tendency  in  the  hu- 
man mind,  to  believe  in  marvellous  cures  from  means  not 
usually  employed  by  those  who  make  the  practice  of  medicine 
their  duty  in  life,  we  occasionally  hear  of  persons  who  have  had 
their  hearing  restored  by  entering  and  remaining  in  chambers — 
such  as  the  caisson  used  in  bridge-building — where  the  air  is 
condensed,  or  from  a  stay  in  the  so-called  pneumatic  cabinets. 
The  exact  observations  of  Magnus,  A.  H.  Smith,  and  Green,  of 
St.  Louis,  show  that  these  accounts  of  cure  of  chronic  non-sup- 
purative  inflammation  are  not  based  on  facts.  On  this  subject 
Dr.  Smith3  says  :  "  Three  cases  of  extreme  deafness  came  under 
my  notice  ;  two  of  them  in  laborers,  and  one  in  the  person  of  a 
gentleman  who  was  advised  by  a  physician  to  visit  the  caisson 
in  the  hope  that  he  might  receive  benefit  from  the  action  of  the 
compressed  air.  In  all  these  cases  the  hearing  was  very  much  im- 
proved while  in  the  caisson,  but  on  returning  to  the  open  air  the 
former  degree  of  deafness  immediately  reappeared."  I  saw  the 
gentleman  to  whom  Dr.  Smith  refers,  and  diagnosticated  his  case 
as  one  of  chronic  proliferous  inflammation  of  the  middle  ear. 

It  might  as  well  be  claimed  that  deafness  is  cured  by  riding 
in  a  railway  carriage,  because  the  hearing  is  temporarily  im- 
proved while  the  patient  is  there,  as  to  assert  that  a  cure  is 
found  in  condensed  air  because  persons  who  enter  an  air-cham- 
ber when  the  atmosphere  is  condensed,  hear  better  during  their 
stay. 

The  only  conceivable  means  by  which  a  sunken  drum-head 
could  be  improved  in  position  and  conducting  power,  by  remain- 

1  Otological  Section,  Berlin  Congress,  1890. 

3  The  effects  of  high  atmospheric  pressure,  before  quoted  in  Chapter  X. 


438  EXHAUSTION    OF    AIR    IN   AUDITORY   CANAL. 

ing  in  a  chamber  of  condensed  air,  would  be  the  rupture  of  the 
membrane  from  the  force  of  the  air,  or  the  opening  of  the  tubes 
by  the  patient's  efforts  to  overcome  the  pressure.  Certainly 
these  ends  can  be  accomplished  in  a  simpler  and  safer  way. 

Dr.  Smith  found,  however,  that  sounds,  such  as  the  ticking 
of  a  watch,  were  not  heard  more,  but  less  distinctly  in  the  con- 
densed air  of  the  caisson  ;  a  fact  which  he  accounts  for  by  sup- 
posing that  the  great  pressure  on  all  parts  of  the  auditory  appa- 
ratus opposes  a  mechanical  obstacle  to  the  freedom  of  vibration. 
"At  the  same  time  the  velocity  of  the  waves  of  sound  is  greater, 
and  hence  the  pitch  is  higher.  A  deep  bass  voice  is  changed  to 
a  treble,  and  the  prolonged,  heavy  sound  of  a  blast  is  so  modi- 
fied as  to  resemble  the  sharp  report  of  a  pistol." 

Magnus '  says  that  the  conduction  of  sound  is  better  in  com- 
pressed air,  and  that  we  can  hear  the  same  tones  better  than  in 
the  ordinary  atmosphere,  provided  that  the  membrana  tympani 
is  not  placed  in  an  abnormal  condition — that  is,  an  over-pressure 
allowed  upon  it. 

EXHAUSTION  OP  THE  AIR  IN  THE  AUDITORY  CANAL. 

Politzer  recommends  the  exhaustion  of  the  air  in  the  exter- 
nal auditory  canal,  by  plugging  the  meatus  with  cotton-wool, 
saturated  with  oil,  as  a  means  of  drawing  out  a  sunken  drum- 
head, when  we  have  reason  to  believe  that  the  tensor  tympani 
is  retracted.  The  patient  closes  the  auditory  canal  in  this  man- 
ner in  the  evening,  and  removes  the  plug  in  the  morning.  If 
the  plug  be  used  two  or  three  times  a  week,  for  two  or  three 
weeks,  and  no  result  be  obtained,  Politzer  considers  the  remedy 
of  no  value. 

Siegle's  otoscope,  or  pneumatic  speculum,  which  has  already 
been  described,  as  a  means  of  diagnosticating  adhesions  be- 
tween the  membrana  tympani  and  the  walls  of  the  tympanic 
cavity,  was  much  used  by  the  late  Dr.  H.  Pinkney,  surgeon 
to  the  New  York  Eye  and  Ear  Infirmary,  as  a  means  of  break- 
ing up  adhesions  in  the  tympanic  cavity,  and  of  improving 
the  hearing.  Dr.  Pinkney  attached  the  syringe  of  a  stomach- 
pump  to  the  apparatus,  and  exhausted  the  air  by  the  use  of  this 
instrument.  The  membrane  should  be  carefully  watched  during 
the  process,  lest  too  extensive  ecchymosis  or  a  rupture  occur. 
I  have  employed  the  apparatus  in  cases  of  chronic  proliferous 
inflammation,  at  Dr.  Pinkney's  suggestion,  but  with  no  satisfac- 
tory results.  I  have  also  cupped  the  membrana  tympani  and 
auditory  canal,  by  placing  a  cup  over  the  auricle,  and  exhaust- 
ing the  air  by  means  of  a  syringe,  but  with  no  beneficial  result. 

1  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  280. 


DELSTANCHE'S  MASSEUK. 


439 


FIG.  95a. — Delstanche's  Masseur. 


DELSTANCHE'S  MASSEUR. 

A  great  advance  in  the  treatment  of  adhesions  between  the 
ossicles  has  been  made  by  Delstanche's  improvement  upon 
Pinkney's  apparatus.  Pinkney's  instrument  was  efficacious  in 
his  hand,  but  it  is  a 
clumsy  instrument, 
which  was  displaced 
by  Ely's  Siegle,  pict- 
ured on  page  368. 
This  in  turn  gives 
way  to  Delstanche's 
instrument,  which  is 
not  only  an  excellent 
means  of  testing  the 
mobility  of  the  ossi- 
cles, but  also  of  treat- 
ing cases  of  chronic 
catarrh  or  chronic 
proliferous  inflam- 
mation with  the  char- 
acteristic rigidity  of  the  ossicles.  By  means  of  this  new  instru- 
ment I  have  had  better  success  in  the  treatment  of  the  rigid 
ossicula,  and  I  have  the  agreeable  opportunity  of  modifying  my 
previously  expressed  opinions  as  to  the  negative  results  of  this 
treatment.  I  think  it  an  adjuvant  of  considerable  value  in  the 
treatment  of  chronic  non-suppurative  inflammations,  in  the  re- 
lief of  tinnitus  aurium,  and  impairment  of  hearing. 

"PARETIC   DEAFNESS." 

No  account  of  chronic  non-suppurative  inflammation  of  the 
middle  ear,  would  be  complete  without  a  mention  of  the  views  of 
Weber-Liel,  as  first  published  in  his  monograph  on  progressive 
impairment  of  hearing,  and  in  an  article  on  affections  of  the 
middle  ear,1  published  in  a  German  encyclopaedia  for  physicians. 
The  upshot  of  this  view  of  the  chronic  affections  of  the  middle 
ear,  belonging  to  the  proliferous  form,  is  that  a  derangement  of 
the  tension  of  any  of  the  pharyngeal,  tubal,  or  tympanic  muscles 
will  bring  about  secondary  vaso-motor  changes  in  all  the  parts 
•within  the  tympanum.  The  most  frequent  form  of  such  a  de- 
rangement of  tension  is  seen  in  a  loss  of  power  of  the  tensor 
palati.  This  induces  a  gradually  increasing  loss  of  hearing  and 


•  :  Ueber  das  wesen  und  die  Heilbarkeit  der  haufigsten  Form  progressive  Schwer- 
horigkeit.     Berlin  :  Hirschwald,  1873. 


440  PARETIC   DEAFNESS. 

tinnitus,  sometimes  accompanied  by  catarrh  of  the  tympanum, 
but  more  likely  to  be  associated  with  sclerosis.  The  restoration 
of  the  normal  muscular  power  should  be  the  first  object  of  treat- 
ment. Weber-Liel  advises  local  electrization  of  the  pharyngeal 
and  tubal  muscles,  the  continuous  current  being  the  most  effec- 
tive. This  must  be  combined  with  careful  attention  to  the  gen- 
eral health.  Hereditary  tendency  to  the  affection  makes  the 
prognosis  unfavorable.  Lessening  of  the  tinnitus  is  one  of  the 
best  signs  in  the  course  of  the  treatment.  A  very  mild  astringent 
spray,  introduced  into  the  tympanum  by  means  of  the  konian- 
tron,  may  also  be  used.  The  tendon  of  the  tensor  tympani  is 
sometimes  excessively  contracted.  If  so  it  is  to  be  divided.  One 
symptom  of  the  retraction  of  the  muscle  is,  that  the  malleus  is 
not  only  drawn  in,  but  slightly  twisted  on  its  axis,  so  that  its 
anterior  surface  is  directed  a  little  forward.  Those  who  wish  a 
fuller  account  will  find  it  in  the  original,  from  which  I  have 
quoted,  or  they  may  study  the  book  of  Dr.  Woakes. l 

For  my  part,  I  can  but  think  Dr.  Weber-Liel's  views  some- 
what fanciful.  His  published  cases,  as  has  been  suggested  by 
Mr.  Hinton,  are  defective,  especially  as  to  their  tests  of  the  condi- 
tion of  the  acoustic  nerve.  Dr.  Woakes  has  somewhat  amplified 
the  views  of  Weber-Liel,  but  his  book  is  essentially  a  reproduc- 
tion of  Weber-Liel's  views.  Woakes  attaches  great  importance 
to  inflammation  of  the  gums  in  children  in  its  reflex  influence 
upon  the  ear.  He  seems  to  think  that  "the  only  obvious  con- 
necting link  between  the  regions  interested  (the  teeth  and  the 
ear)  is  the  continuity  of  nerve-fibre,"  and  this  he  finds  in  the 
relations  of  the  vaso-motor  nerves.  This,  in  my  opinion,  is  beg- 
ging the  whole  question,  for  the  direct  connection  between  the 
buccal  cavity  and  the  Eustachian  tube  is  obvious  enough  to 
allow  of  the  propagation  of  inflammation  by  simple  continuity 
of  tissue,  without  the  intervention  of  the  vaso-motor  nerves. 

Dr.  Woakes  states  that  he  had  embodied  his  views  on  the 
deteriorating  effect  on  the  hearing  power  of  certain  pathological 
states  of  the  palato-tubal  muscles,  in  a  paper  which  he  read  be- 
fore the  British  Medical  Association,  without  knowing  Weber- 
Liel's  paper,  although  "Progressive  Impairment  of  Hearing" 
had  been  published  for  some  time.  Woakes's  "  Paretic  Deafness," 
however,  corresponds  with  great  exactness  to  Weber-Liel's  "Pro- 
gressive Impairment  of  Hearing,"  and  what  has  been  said  of  the 
views  of  the  one,  may  be  said  of  the  other.  The  objections  to 
referring  cases  of  chronic  proliferous  inflammation  to  catarrh, 
is  one  in  which  I  fully  sympathize,  but  I  do  not  think  we  have 

• 

1  On  Deafness,  Giddiness,  and  Xoises  in  the  Head.     London,  1880. 


RESULTS   OF   TREATMENT.  441 

found  the  way  out  in  diagnosis,  by  ascribing  their  origin  to  par- 
alysis of  the  pharyngeal,  tubal,  or  tympanic  muscles,  nor  in 
treatment  by  intra-tubal  electricity,  hydrobromic  acid,  strychnia, 
or  the  sesqui-carbonate  of  ammonia.  I  think  it  possible  that 
some  of  Weber-Liel's  cases,  as  well  as  those  of  Dr.  Woakes, 
belong  rather  to  the  labyrinth  than  to  the  middle  ear.  For 
myself,  I  think  I  have  been  in  the  habit,  in  former  days,  of  for 
getting  that  the  cochlea,  like  the  retina,  may  become  the  seat  of 
chronic  disease. 


RESULTS  OF  TREATMENT. 

In  my  opinion,. the  results  of  treatment  of  chronic  non-sup- 
purative  inflammation  of  the  middle  ear,  will  never  be  very  grat- 
ifying. It  is  essentially  an  incurable  affection.  It  may  often  be 
alleviated  and  sometimes  arrested,  but  in  adults  never  cured.  It 
is  pre-eminently  a  local  disease — that  is  to  say,  a  person  with  this 
variety  of  aural  disease  may  have  the  best  general  treatment  the 
world  affords,  and  be  under  the  most  appropriate  hygienic  condi- 
tions ;  he  may  live  in  a  climate  like  that  of  Nice,  Mentone,  Naples, 
Aiken,  or  St.  Augustine,  and  then  he  will  not  recover  from  his 
aural  disease ;  nay,  more,  he  will  continue  to  grow  slowly  but 
gradually  worse  if  his  pharynx,  Eustachian  tubes,  and  middle 
ear  are  not  treated  by  the  appropriate  appliances  and  remedies, 
and  sometimes  even  if  they  are.  And  yet  a  change  from  a  harsh 
climate  with  long  winters,  to  a  mild  one,  will  sometimes  be  of 
avail  in  lessening  the  horrors  of  tinnitus  aurium,  and  arresting 
the  advance  of  disease  of  the  middle  ear.  Just  how  much  can 
be  done  in  this  way,  it  is  difficult  to  estimate,  for  catarrhal  pa- 
tients seem  to  grow  worse  in  Colorado,  which  is  so  well  adapted 
for  many  forms  of  phthisis.  The  changes  of  temperature  in  mild 
climates,  are  also  felt  very  much  by  aural  patients  who  have 
nasal  and  pharyngeal  disease.  One  of  my  patients  with  chronic 
proliferous  inflammation,  has  found  the  tinnitus  aurium  greatly 
relieved  by  a  winter  in  the  mountains  of  North  Carolina.  An- 
other, with  catarrhal  inflammation,  was  happy  in  Florida,  until 
malaria  destroyed  her  peace.  Some  patients  find  the  seashore, 
especially  Newport  and  Narragansett,  of  benefit  to  the  naso- 
pharyngeal  region,  while  others  cough  and  sneeze,  and  their 
"ears  fill  up"  incessantly  there.  On  the  whole,  I  think  the 
mountains  are  better  for  aural  patients  in  summer.  But  I  must 
confess  that  I  have  no  exact  opinions  as  to  the  influence  of 
climate  upon  non-suppurative  disease  of  the  middle  ear.  The 
disease  of  the  ear,  is  the  last  link  in  a  long  chain  of  improper 
conditions,  and  should  never  be  considered  as  a  primary  affec- 


442  RESULTS   OF  TREATMENT. 

tion,  as  an  entity  to  be  subjugated  or  driven  out  by  special 
means  adapted  to  many  cases.  It  exists  in  this  generation,  in 
larger  proportion  than  it  will  in  the  next.  For  acute  disease 
will  then  be  properly  considered  and  treated,  the  hygienic  man- 
agement of  the  human  body  will  be  better  understood.  Just  as 
chronic  suppuration  with  its  consequences,  is  markedly  lessened 
in  our  own  time,  as  the  result  of  a  wise  appreciation  of  "ear- 
ache," and  acute  catarrh,  and  suppuration,  so  will  chronic  ca- 
tarrh be  lessened  as  the  importance  of  incipient  aural  disease  is 
more  and  more  appreciated.  If  the  picture  of  the  prognosis  of 
chronic  affections  of  the  ear  is  a  gloomy  one  to  the  young  and 
enthusiastic  practitioner,  he  must  find  his  consolation  in  lessen- 
ing their  number  in  the  next  decade,  by  a  proper  treatment  of 
acute  aural  disease  in  this. 

There  are  yet,  however,  few  medical  colleges  in  this  country 
where  the  otological  course  is  complete  or  exact.  Worse  than 
this,  attendance  upon  the  lectures  that  are  given,  is  generally 
not  compulsory.  It  is  only  in  special  hospitals,  and  post-grad- 
uate colleges,  that  any  adequate  instruction  is  given,  except  in 
very  few  instances.  All  this  must  be  changed,  before  we  can 
expect  a  knowledge  of  aural  pathology  and  therapeutics,  and 
with  this  a  decrease  in  the  proportion  of  neglected  and  incurable 
cases. 

If  I  were  to  sum  up  my  conclusions  after  twenty  years  of  work 
in  this  field,  I  should  say  that — 

1.  Chronic  catarrhal  inflammation  in  young  subjects,  is  sus- 
ceptible of  relief  and  cure  in  a  large  proportion  of  cases. 

2.  Chronic  catarrhal  inflammation  in  adults,  is  susceptible  of 
relief  and  alleviation  in  about  twenty  per  cent,  of  the  cases  :  of 
cure  in  none. 

3.  Chronic  proliferous  inflammation  remains  as  yet  incurable,, 
and  is  not  susceptible  of  alleviation  or  relief,  either  in  the  young; 
or  old  subject,  in  more  than  five  per  cent,  of  the  cases. 


CHAPTER  XVI. 

CHBONIC  SUPPTJBATION  OF  THE  MIDDLE  EAE. 

Consequence  of  Acute  Suppuration. — Otorrhoea  an  Improper  Term. — Often  confounded 
with  Chronic  Inflammation  of  the  Canal.— Kelative  Frequency  of  the  two  Affec- 
tions.— Symptoms. — Perforations  of  MembranaTympani.  —Treatment. — Syringing. 
— Astringents. —  Fluids. — Powders. — Electricity. — Artificial  Membrana  Tympani. 
— Cases.  — Prognosis. 

THE  chapters  in  which  acute  aural  catarrh  and  acute  suppura- 
tion have  been  considered,  have  prepared  us  for  the  description 
of  the  disease  properly  known  as  chronic  suppuration  of  the 
middle  ear,  which  is  a  direct  consequence  of  these  affections.  It 
was  formerly  almost  universally  known  and  described  as  otor- 
rhoea.  But  this  term,  simply  meaning  a  discharge  from  the  ear, 
and  being  one  that  does  not  in  any  proper  way  define  the  seat  or 
character  of  the  disease,  should,  I  think,  be  banished  from  the 
nomenclature  of  otology.  Chronic  suppuration  of  the  middle 
ear  is  the  affection  which,  among  the  laity,  is  called  "a  running 
from  the  ear,"  and  which  has  been  so  lightly  regarded  by  the 
profession,  that  every  year  people  die  from  its  direct  results,  and 
under  the  observation  of  physicians,  without  the  suspicion  that 
the  disease  of  the  ear,  and  of  the  ear  alone,  was  the  cause  of 
their  death.  In  this,  and  in  following  chapters,  I  shall  attempt  to 
set  forth,  in  a  plain  and  simple  manner,  the  exact  nature  of  this 
disease,  and  the  reasons  why  it  should  never  be  neglected,  but 
always  kept  under  the  most  careful  observation  and  treatment. 

The  name  chronic  suppuration  of  the  middle  ear  means  a 
great  deal.  It  comprehends  a  large  variety  of  disease  in  one  of 
the  important  parts  of  the  body.  The  term  chronic  suppuration 
of  the  middle  ear,  usually  implies  a  perforation  of  the  drum-head 
or  membrana  tympani.  In  exceedingly  rare  cases,  there  may  be 
a  suppuration  in  the  tympanic  cavity  and  mastoid  cells,  espe- 
cially in  the  latter,  for  weeks  or  even  months,  without  the  occur- 
rence of  a  perforation  of  the  delicate  but  firm  membrane  that 
forms  the  boundary  between  the  middle  and  the  external  ear. 
In  all  but  exceptional  cases,  however,  when  chronic  suppuration 
of  the  middle  ear  is  stated  to  be  the  diagnosis  of  a  given  case,  it 
is  meant  that  the  ulceration  involves  the  drum-head. 


444  FREQUENCY  OF  AFFECTIONS  OF  EXTERNAL  AND  MIDDLE  EAU. 


Chronic  suppuration  of  the  middle  ear  is  often  confounded 
•with  that  rare  disease,  chronic  suppuration  of  the  external  audi- 
tory canal.  Very  many  times  patients  have  been  brought  to 
me,  with  what  the  attending  physician  supposed  to  be  merely  an 
external  otitis,  but  which  proved  to  be  really  a  case  of  suppura- 
tion of  the  middle  ear,  with  perforation  of  the  membrana  tym- 
pani.  When  it  was  demonstrated  that  the  pus  had  its  origin, 
not  from  the  auditory  canal,  but  from  the  middle  ear,  it  was 
usually  an  easy  task  to  convince  the  person  affected,  of  the  dan- 
ger of  a  neglect  of  the  disease.  I  feel  confident  that  this  error 
as  to  the  origin  of  the  affection,  is  in  many  cases  the  cause  of  its 
neglect.  An  eczema,  or  a  so-called  seborrhcea,  or  even  a  sup- 
purative  external  otitis,  may,  perhaps,  when  occurring  with 
young  children,  be  left  to  itself  or  to  general  hygienic  attention 
and  tonic  treatment  with  comparative  impunity ;  but  the  best 
of  such  care  will  not  usually  avail  to  stop  a  formation  of  pus  in 
the  cavity  of  the  tympanum  or  the  mastoid  cells,  unless  local 
treatment  is  also  employed. 

We  might  almost  take  it  for  granted,  if  such  a  practice  were 
not  improper  in  a  physician  who  claims  to  observe  with  exact- 
ness, that  any  case  of  long-existing  suppuration  in,  or  discharge 
of  pus  from  the  ear,  will  be  found  to  have  its  origin  behind,  and 
not  in  front  of  the  membrana  tympani. 

I  have  already  spoken  of  this  fact  of  the  comparative  infre- 
quency  of  suppurative  affections  of  the  outer  ear,  as  compared 
with  those  of  the  middle  part  of  the  organ ;  but  the  following 
table  brings  it  out  more  strikingly  than  the  mere  assertion  : 

Table  showing  the  Relative  Frequency  of  Inflammatory  Affections  of  the  External 
Ear  and  Suppuration  of  the  Middle  Ear. 


Hospital. 

Year  or  period. 

Inflamma- 
tion of  ext. 
and.  canal, 
including  ec- 
zema. 

Suppuration 
of  middle 
ear. 

Manhattan  (New  York)  Eye  and  Ear  Hospital  .  . 
New  York  Eye  and  Ear  Infirmary  

20  vears 
1889 

824 
164 

6,675 
1,173 

New  York  Ophthalmic  and  Aural  Institute  
Brooklvn  Eye  and  Ear  Hospital  

1889 
21  vears 

52 
1,245 

296 

6,843 

Massachusetts  Eye  and  Ear  Infirmary  

1889 

203 

679 

Salem  Hospital  

15  vears 

123 

565 

St.  Michael's  Hospital  (Newark,  N.  J.)  

1888 

50 

178 

Newark  Eve  and  Ear  Infirmary  

1889 

105 

374 

Illinois  Eye  and  Ear  Infirmary  

1885-1886 

32 

467 

Buffalo  Eye  and  Ear  Infirmary  

1889 

8 

48 

2,806 

17,298 

All  the  cases  under  the  heading  "Inflammation  of  the  Auditory  Canal,"  were  not 
necessarily  suppurative  ;  while  I  have  been  careful  to  place  only  the  suppurative  cases 
in  the  middle  ear  column. 


STATISTICS   OP   CHRONIC   SUPPURATION.  445 

It  will  be  seen  by  the  table,  that  the  cases  of  suppuration  of 
the  middle  ear  preponderate  over  the  cases  of  external  otitis 
of  all  kinds,  in  a  proportion  exceeding  that  of  five  to  one.  I  am 
inclined  to  believe  that  the  proportion  is  actually  even  larger 
than  this,  and  that  in  some  cases  the  diagnosis  was  made  of 
inflammation  of  the  canal,  simply  because  at  the  outset  the  in- 
flammation was  so  great  as  not  to  allow  of  a  view  of  the  drum- 
head, which  was  afterward  found  to  be  affected.  If  I  had  been 
able  to  exclude  the  non-suppurative  diseases  of  the  canal,  as  I 
have  those  of  the  middle  ear,  the  preponderance  of  middle  ear 
cases  would  have  been  much  greater. 

Of  4800  cases  of  my  own,  observed  in  private  practice,  there 
were  1011  cases  of  suppuration  of  the  middle  ear  ;  of  these  201 
were  cases  of  acute  suppuration,  and  810  of  chronic.  There 
were  265  cases  of  inflammation  of  the  canal,  including  85  cases 
of  eczema  and  13  of  aspergillus. 

Symptoms. — A  discharge  of  pus  is  the  most  striking  symptom 
in  chronic  suppuration  of  the  middle  ear.  There  can  hardly  be 
such  a  thing  as  a  chronic  suppuration  in  this  part  without  a  per- 
foration of  the  drum-head,  through  which  the  pus  escapes.  The 
term  perforation,  in  its  turn,  includes  a  great  variety  of  patho- 
logical conditions. 

For  example,  the  drum-head  may  be  entirely  swept  away ; 
one-half  of  it  may  be  gone  ;  one-third  of  it  may  be  gone  ;  only  a 
small  opening  about  as  large  as  the  head  of  a  pin  may  exist ; 
two  openings  may  exist ;  so  that  in  the  very  appearance  of  the 
drum-head  we  may  meet  the  greatest  difference  in  conditions. 

Besides,  polypi  .may  be  seen  through  the  perforation,  spring- 
ing from  the  tympanic  cavity,  or  there  may  be  small  growths 
or  granulations  hardly  to  be  dignified  by  the  term  polypi.  We 
may  find  the  opening  covered  by  hardened  wax,  or  even  by 
dried  pus.  Quite  large  quantities  of  muco-pus,  pus,  or  of  mucus, 
or  of  a  fluid,  Jike  serum,  may  conceal  the  opening  and  be  formed 
in  a  quantity  sufficient  to  cause  a  constant  flow  into  the  audi- 
tory canal,  or  the  quantity  may  be  very  small,  and  only  to  be 
detected  on  careful  examination.  In  any  consideration  of  the 
diseases  of  the  middle  ear,  the  practitioner  should  remember 
that  the  mastoid  cells,  as  well  as  the  cavity  of  the  tympanum, 
are  an  integral  portion  of  this  anatomical  region.  Hence  it  is 
that  the  lining  membrane  of  the  mastoid  is  usually  involved  in 
any  inflammation  of  the  middle  ear. 

As  will  be  seen  by  reference  to  a  case  recorded  in  a  chapter 
on  "The  Consequences  of  Chronic  Suppuration,"'  pus  may  form, 
exist  for  weeks  in  the  mastoid  process,  and  not  at  all  involve 


446  CHRONIC   SUPPURATION — SYMPTOMS. 

the  drum-head.  Such  cases  are.  however,  very  exceptional.  A 
chronic  suppuration  of  the  middle  ear,  almost  always  involves 
an  ulcerative  perforation  of  the  membrana  tympani.  When  the 
former  term  is  used,  the  latter  state  of  things  is  understood  to 
exist,  whatever  other  changes  of  structure  may  have  occurred. 
The  discharge  of  pus  is  sometimes  very  profuse  and  constant, 
so  that  it  streams  from  the  ear.  This  is  more  apt  to  be  the  case 
in  young  children,  although  it  occurs  in  adults.  In  such  cases 
the  auricle  and  external  auditory  canal  become  red,  tender,  and 
even  excoriated  from  the  irritation  of  the  pus  in  which  the  parts 
are  bathed.  In  other  and  more  numerous  cases,  the  pus  lies 
only  at  the  bottom  of  the  canal  upon  the  remains  of  the  mem- 
brana tympani  and  in  the  cavity  of  the  tympanum,  enveloping 
the  chain  of  bones,  and  passing  into  the  cavities  called  the  mas- 
toid  cells.  In  still  other  cases,  there  is  no  continuous  outflow  of 
pus,  either  by  day,  or  at  night  upon  the  pillow  ;  but  at  intervals 
there  is  a  slight  increase  of  the  unpleasant  symptoms,  which 
even  assume  the  dignity  of  an  earache,  after  which  a  free  dis- 
charge of  pus  from  the  ear  occurs.  On  questioning  such  pa- 
tients in  regard  to  the  existence  of  a  discharge  from  the  ear, 
they  will  usually  state  that  none  occurs,  except  after  an  attack 
of  earache,  although  the  fact  is  that  pus  is  always  lying  in  the 
part.  If  we  examine  such  an  ear  when  the  discharge  is  sup- 
posed to  have  ceased,  we  shall  find  at  the  bottom  of  the  canal, 
and  in  the  cavity  of  the  tympanum,  a  hardened  mass  of  dried 
pus  covered  over  by  cerumen  or  epidermis.  Impacted  cerumen 
is  quite  a  frequent  occurrence  in  the  course  of  a  chronic  suppu- 
rative  process  in  the  middle  ear.  We  shall  often  come  to  an 
erroneous  conclusion  as  to  the  cause  of  a  loss  of  hearing,  if  we 
judge  of  the  case  from  the  presence  of  hardened  cerumen  in  the 
auditory  canal,  without  getting  the  history. 

The  membrana  tympani  presents  the  most  varied  appear- 
ance in  different  cases  of  chronic  suppuration  in  the  middle  ear ; 
sometimes,  it  is  entirely  swept  away,  and  all  the  ossicula  with 
it.  The  cavity  of  the  tympanum  is  then  an  empty  cavity  open- 
ing upon  the  canal.  Again,  there  is  a  rim  remaining,  with  per- 
haps the  incus  and  stapes  in  situ,  or  dislocated,  but  yet  present, 
while  the  malleus  is  gone.  In  other  cases  the  ossicula  are  intact 
and  in  position,  but  there  are  clearly  cut,  well-defined  holes, 
from  one  to  three  in  number,  in  the  drum-head.  The  chromo- 
lithographs exhibit  such  a  perforation,  with  the  blood-vessels 
that  are  about  to  repair  it,  radiating  toward  the  opening.  Some- 
times one-half  of  the  membrane  is  cleanly  cut  away.  In  fact, 
the  appearance  of  the  membrane  is  as  various  as  the  number  of 
cases.  The  description  of  no  one  case  will  do  for  another. 


CHRONIC   SUPPURATION — SYMPTOMS.  447 

Besides  polypi,  exostoses'  may  exist  in  the  canal,  or  even  in 
the  walls  of  the  tympanic  cavity ;  the  bone  may  be  exposed,  i.e., 
denuded  of  its  periosteum,  roughened,  and  in  a  condition  of 
caries.  The  seventh  nerve,  in  its  passage  through  the  aqueduct 
of  Fallopius,  may  be  destroyed  by  the  morbid  process,  when  the 
smirk  and  uncovered  eye  of  facial  paralysis  are  added  to  the  dis- 
gusting detail  of  the  ravages  of  disease. 

After  these  facts  are  brought  to  recollection,  I  think  I  am 
justified  in  styling  the  term  chronic  suppuration  of  the  middle 
ear,  a  very  comprehensive  one.  It  is  an  erroneous  method  of 
teaching  which  would  describe  suppuration  of  the  tympanic 
cavity  and  mastoid  cells  by  the  term  otorrhcea,  and  I  think  that 
a  discussion  of  the  treatment  of  a  discharge  from  the  ear,  with- 
out a  comprehensive  view  of  the  important  pathological  condi- 
tions which  may  exist  in  this  part  of  the  body,  must  be  in  its 
very  nature  misleading.  No  discussion  of  the  treatment  of  the 
formation  and  discharge  of  pus  from  the  tympanum,  will  be 
profitable  unless  there  precedes  it  a  full  understanding  of  the 
anatomical  -and  pathological  conditions  which  allow  the  pus  to 
be  formed  and  collected. 

If  the  middle  ear  were  a  simple  canal  or  cavity,  the  principles 
at  the  basis  of  the  treatment  would,  perhaps,  be  the  same  that 
they  are  now,  but  it  comprises  a  series  of  anatomical  parts,  and 
the  details  in  carrying  out  these  principles  are  very  different, 
and  are  much  more  varied  than  they  would  be  were  we  dealing 
with  a  simple  and  easily  bounded  space.  It  is  the  anatomy  of 
the  middle  ear,  that  makes  the  treatment  of  its  diseases  not  an 
entirely  simple  matter. 

I  do  not  think  there  is  any  one  point  more  than  another,  in 
the  membrana  tympani,  where  perforations  are  apt  to  occur. 
Sir  William  Wilde,  and  Moos,  quoted  by  Hinton,1  affirm  that 
they  are  most  frequently  situated  in  the  anterior  and  lower  part 
of  the  membrane,  where  the  air  blown  through  the  Eustachian 
tube  impinges.  Hinton,  has  seen  quite  as  many  in  the  inferior 
and  posterior  segments,  an  experience  which  my  own  quite  con- 
firms. I  have  found  them  in  every  quadrant  of  the  drum-head. 

Perforations  are  sometimes  so  small  as  not  to  be  easily  recog- 
nized, unless  air  is  forced  through  the  Eustachian  tube  and  made 
to  pass  through  them.  As  has  been  stated  in  the  preceding 
chapter,  Wilde,  thought  that  a  pulsation  at  the  bottom  of  the 
auditory  canal  was  pathognomonic  of  perforation  of  the  drum- 
head. Where  this  pulsation  occurs,  it  is  a  very  suspicious  cir- 
cumstance :  but  as  has  been  before  said  in  this  volume,  a  thin 


Guy's  Hospital  Reports,  Third  Series,  vol.  xii. 


448  ALBUMINURIA   FROM   CHRONIC    SUPPURATION. 

membrana  tympani.  in  a  state  of  acute  catarrhal  inflammation, 
will  sometimes  exhibit  this  phenomenon  when  the  drum-head  is 
intact.  Mr.  Hinton  remarks  in  his  excellent  paper  on  "Per- 
forations of  the  Membrana  Tympani,"  from  which  I  have  just 
quoted,  "This  motion  (pulsating)  is  imparted  by  the  blood,  and 
implies  not  necessarily  an  aperture,  but  a  thin  surface  of  fluid  in 
•contact  with  a  beating  vessel."1  The  complete  absence  of  the 
membrana  tympani,  especially  if  the  mucus  lining  of  the  tym- 
panic cavity  have  a  granular  or  velvety  appearance,  is  often 
very  puzzling.  Such  cases  will  sometimes  require  the  most 
careful  cleansing  before  we  can  determine  how  much,  if  any,  of 
the  drum-head  remains. 

We  need  not  enter  into  any  detailed  account  of  the  condition 
of  the  pharynx  and  Eustachian  tubes  in  the  affection  now  under 
consideration,  since  this  subject  has  been  so  fully  dwelt  upon  in 
treating  of  the  chronic  non-suppurative  inflammations.  It  may 
be  sufficient  to  say  here  that  we  find  in  chronic  suppuration,  as 
well  as  in  all  the  varieties  of  inflammations  of  the  middle  ear, 
except  the  purely  proliferous  forms,  that  the  naso-pharyngeal 
region  has  been  the  usual  point  of  origin  of  the  disease,  and 
that  any  successful  management  of  the  ear,  will  require  great 
attention  to  the  pharynx  and  Eustachian  tube. 

The  general  health  of  a  patient  affected  with  chronic  suppu- 
ration of  the  middle  ear  is  usually  impaired,  even  if  none  of  the 
serious  consequences  have  occurred.  Such  a  drain  upon  the 
system  is  not  tolerated  with  equanimity  by  nature.  Dr.  Hack- 
ley  "  has  found  albuminuria  in  a  number  of  cases  of  chronic  sup- 
puration of  the  middle  ear,  where  there  was  no  apparent  cause 
for  the  disease,  except  the  long-continued  secretion  of  pus  in  the 
tympanic  cavity.  He  is  inclined  to  think,  that  such  cases  are 
analogous  to  those  of  the  development  of  lardaceous  kidney  from 
debilitating  diseases. 

The  fact  that  a  running  sore  is  detrimental  to  the  continu- 
ance of  good  general  health,  would  scarcely  need  assertion, 
were  it  not  that  the  author,  in  common  with  many  others,  has 
observed  a  very  deeply  rooted  idea  among  the  laity — an  idea 
that  was  first  inculcated,  and  which  is  even  now  encouraged  by 
the  profession — that  there  is  no  harm  resulting  from  a  chronic 
ulcerative  process  in  the  ear,  when  it  is  well  out  of  sight.  It  is 
even  at  times  gravely  asserted  that  such  a  drain  to  the  system 
is  salutary,  as  if  our  Creator  would  not  have  made  the  human 
race  with  such  a  one  if  it  were  necessary.  I  have  seen  persons 
who  allow  their  ears  to  become  an  offence  to  the  nostrils  of  those 

1  Loc.  cit. ,  p.  630.        *  Verbal  communication  at  New  York  Ophthalmological  Society, 


SUPPOSED  DANGER  FROM  STOPPING  THE  DISCHARGE.  449 

I 

about  them,  because  they  have  been  advised  by  their  physician 
that  it  was  not  best  to  "meddle  with  the  ear."  If  my  reader 
feels  that  I  have  said  too  much  on  this  subject,  in  the  different 
parts  of  this  volume,  I  beg  that  he  will  ask  himself  how  many 
cases  of  death  he  has  known  as  the  result  of  a  suppurative  pro- 
cess in  the  ear,  consult  his  fellow  practitioners  on  the  same 
point,  and  finally  investigate  the  statistical  tables  of  deaf  and 
dumb  asylums.  In  the  answers  to  these  queries  will  be  found 
a  complete  justification  of  my  earnestness  on  this  point.  The 
anatomy  of  the  middle  ear,  showing,  as  it  does,  the  relations  of 
this  small  portion  of  the  organism  to  the  most  important  parts 
of  the  system,  to  the  great  arterial  and  venous  vessels,  to  the 
nervous  system,  to  the  organs  of  respiration,  is  also  of  itself  a 
sufficient  proof,  of  the  necessary  importance  of  a  long-continued 
suppuration  in  this  part. 

There  still  exists,  however,  even  in  the  minds  of  some  phy- 
sicians, a  prejudice  against  the  stoppage  of  a  purulent  discharge 
from  the  ear.  In  the  laity  this  prejudice  is  widely  spread,  and 
is  chiefly  dependent  upon  the  erroneous  teachings  of  the  older 
French  writers,  Du  Verney  and  Itard.  As  Wilde  shows,  in  his 
classic  article  upon  this  disease  in  his  text-book,  "Because  it 
was  observed  that  on  the  supervention  of  cerebral  disease,  dis- 
charges from  the  auditory  canal  have  lessened,  practitioners 
mistaking  the  effect  for  the  cause,  have  been  led  to  believe  that 
the  sudden  'drying  up'  produced  a  metastasis  to  the  brain,  a 
notion  as  crude  as  it  is  unsupported."  There  is,  I  believe,  no 
pathological  experience  on  record  which  can  sustain  the  quite 
common  assertion  that  it  is  dangerous  to  stop  a  discharge  from 
the  ear.  There  are  some  cases  on  record — of  which  there  are, 
alas  !  many  more  than  were  ever  recorded — where  disease  of 
the  brain  has  occurred  from  the  extension  of  a  neglected  sup- 
puration to  the  cerebral  membranes  and  substance,  and  the  dis- 
charge from  the  ear  has  nearly  ceased  •  but  these  certainly  form 
no  argument  against  the  arrest  of  an  ulcerative  process  before 
any  parts  beyond  the  cavity  of  the  tympanum  are  involved. 

He  who  believes  that  we  can  easily  cause  a  discharge  of  pus 
to  cease,  after  caries  of  the  temporal  bone  has  occurred,  will 
find  many  cases  which  will  cause  him  to  doubt  the  efficacy  of 
his  therapeutics.  As  well  might  we  refuse  to  heal  an  ulcerated 
hip-joint,  as  to  neglect  to  check  a  discharge  from  a  diseased 
membrana  tympani  or  lining  membrane  of  the  tympanic  cavity. 

It  is  doubtless  true,  judging  from  the  histories  of  cases  and 

the  inspection  of  the  membrana  tympani,  in  which  cicatrices 

occur,  that  many  cases  of  chronic  suppuration  are  cured  with 

very  slight  treatment,  or  with  none  at  all.     The  fact  remains, 

29 


450  HEARING   POWER   WITH    PERFORATION. 

however,  that  many  of  the  neglected  cases  do  not  so  recover, 
and  after  a  purulent  discharge  from  the  ear  has  once  set  in, 
"we  can  never  tell,'7  to  quote  again  the  words  of  Wilde,  which 
should  be  impressed  upon  the  attention  of  every  practitioner  of 
medicine,  "how,  ivhen,  or  where  it  will  end,  or  what  it  may 
lead  to."1 

A  careful  treatment  is  usually  required  to  check  the  dis- 
charge and  treat  the  ulcerated  membrana  tympani.  and  restore 
the  hearing  power.  Even  with  the  most  careful  and  skilful 
treatment,  we  cannot  always  succeed  in  all  of  these  things.  In 
some  rare  cases  we  do  not  succeed  in  any  of  them ;  but  the  pa- 
tient, in  spite  of  our  best  efforts,  will  go  on  to  his  doom. 

The  degree  of  the  impairment  of  hearing,  in  cases  of  chronic 
aural  suppuration,  is  very  variable.  It  depends,  of  course,  upon 
many  factors ;  for  example,  the  condition  of  the  Eustachiaii 
tube,  and  the  integrity  of  the  structure  in  the  cavity  of  the  tym- 
panum. The  hearing  power  by  no  means  depends  upon  the 
presence  or  absence  of  the  membrana  tympani.  The  chief  func- 
tion of  this  membrane  is  probably  to  protect  the  tympanic  cav- 
ity, and  not  merely  to  transmit  the  vibrations  of  the  atmosphere, 
which  when  conveyed  to  the  acoustic  nerve  we  call  sound.  I 
know  some  persons  who  have  large  perforations  in  each  mem- 
brana tympani,  and  who  yet  hear  well  enough  for  all  the  ordi- 
nary purposes  of  life,  although  not  with  perfection.  One  notable 
instance  of  this  kind  is  that  of  a  busy  physician  of  my  acquaint- 
ance. As  has  been  already  said,  in  the  last  chapter,  Sir  Astley 
Cooper,  in  a  paper  published  in  the  "  Transactions  of  the  Royal 
Society,"  in  1800,*  showed  that  there  could  be  very  good  hearing 
powers  with  a  perforate  membrana  tympani ;  and  yet  I  very 
often  hear  the  question  asked,  as  well  by  physicians  as  by  lay- 
men, if  anything  can  be  done  when  there  is  a  hole  in  this  mem- 
brane ;  and  it  is  also  often  stoutly  asserted  that  when  this  mem- 
brane is  once  gone,  the  hearing  is  irrevocably  lost.  This  false 
idea  continues  to  prevail,  not  only  in  spite  of  scientific  demon- 
stration of  more  than  seventy  years  ago,  but  also  in  the  face  of 
clinical  facts  that  are  every  day  within  the  reach  of  each  atten- 
tive physician.  Truly,  a  lie  will  travel  around  the  world,  while 
truth  is  putting  on  its  boots. 

The  parts  which  form  the  middle  ear  make  up  a  cavity  which 
has  perhaps  as  many,  if  not  more,  important  anatomical  re- 
lations than  any  one  of  similar  size  in  the  human  body.  The 
cavity  of  the  tympanum  is  covered  above  by  a  thin,  rarefied 
bony  plate,  which  is  in  direct  communication  with  the  cerebral 


1  Text-book,  p.  407.  *  Philosophical  Transactions,  Part  I.     1800. 


REMOVAL  OF  PUS  rEKOM  TYMPANUM.  451 

meninges  ;  the  floor  is  close  to  the  great  jugular.  Its  internal 
wall  is  the  labyrinth  wall,  with  its  two  fenestrse,  covered  only 
by  thin  membrane  and  opening  into  the  ramifications  of  the 
acoustic  nerve  and  the  fluid  which  is  continuous  with  that  of 
the  sub-arachnoid  space ;  while  externally  we  have  a  membrane 
of  about  the  thickness  of  letter-paper. 

Treatment, — The  proper  treatment  of  a  chronic  suppuration 
in  such  a  space  should  be  a  matter  of  the  greatest  solicitude.  It 
involves  not  alone  the  hearing  power,  but  also  the  life  of  the 
patient.  There  is  one  pre-requisite  to  the  successful  treatment 
of  this  affection,  and  that  is,  a  complete  removal  of  all  the  mor- 
bid material  that  has  formed  in  the  middle  ear.  This  is  simply 
another  way  of  stating  that  the  parts  must  be  thoroughly 
cleansed. 

As  we  have  seen  in  the  discussion  of  the  various  affections 
of  the  middle  ear,  their  starting-point  is  usually  in  the  fauces  or 
pharynx.  But  the  ulcerative  process  which  has  been  set  up  in 
the  tympanic  cavity  has  broken  through  the  membrana  tym- 
pani,  and  the  result  shows  itself  in  the  external  auditory  canal. 
The  problem  to  be  solved  is,  how  may  we  stop  the  ulcerative 
process,  heal  the  membrana  tympani,  and  restore  the  hearing 
power,  which  has  been  impaired  by  the  inflammatory  process  in 
the  sound-conducting  apparatus  ?  In  many  cases,  however,  we 
may  be  well  satisfied  if  two  of  these  requirements  be  fully  ful- 
filled, while  the  hearing  power  is  improved.  A  radical  cure  of 
a  suppurative  process  in  the  middle  ear,  of  long  standing,  is, 
from  the  very  nature  of  things,  sometimes  impossible. 

The  old  method  of  treating  such  a  suppuration  was  to  advise 
the  patient  to  syringe  the  ears  with  soap  and  water,  put  a  blister 
on  the  mastoid  process,  and  at  the  same  time  the  physician  got 
the  system  to  rights  by  using  alteratives,  laxatives,  and  purga- 
tives. The  general  principle  of  treatment  thus  held  in  view 
was  correct,  but  in  the  matter  of  the  local  treatment,  which  is 
of  far  more  importance  than  the  constitutional,  altogether  too 
much  was  left  to  the  supposed  knowledge  and  skill  of  the  pa- 
tient or  his  attendant. 

Perhaps  not  more  than  one  layman  in  a  hundred  can,  with- 
out instruction,  thoroughly  cleanse  an  ear  by  syringing.  It  is 
generally  thought  that  any  person  can  syringe  an  ear.  when  the 
facts  are  that  no  patient  can  properly  cleanse  his  own  ear.  and 
almost  every  one  requires  instruction  before  he  can  even  syringe 
the  ear  of  another.  In  one  of  the  preceding  chapters  of  this  book 
(see  page  133),  the  proper  method  of  syringing  has  been  care- 
fully described,  so  that  we  need  not  dwell  upon  the  subject  again. 


452  OBJECTIONS  TO  THE  SYKINGE. 

Objections  have  been  made  to  the  use  of  the  syringe.  One 
authority,  for  whom  I  have  a  great  respect,  says,  in  referring  to 
the  cleansing  of  the  ear  from  pus,  and  in  italics,  too,  "  The  syr- 
inge, as  a  rule,  is  not  to  be  used." '  When  differences  of  opinion 
like  this  as  to  modes  of  treatment  arise,  there  is  not  much  to  be 
said  except  to  show  that  one  recognizes  his  own  standpoint,  and 
the  difficulties  of  it,  and  gives  good  heed  to  the  contrary  one.  I 
think  I  am  not  ignorant  of  the  abuse  of  syringing,  or  of  the  fact 
that  much  that  is  called  cleansing  the  ear  by  syringing  has  no 
right  to  such  a  name.  I  am  also  well  aware  of  the  ill  effects  in 
isolated  cases  from  syringing.  I  once  reported "  a  case  in  which 
a  gentleman  who  consulted  me  suffered  so  seriously  from  syn- 
cope, after  a  very  gentle  syringing  of  the  ear,  that  for  some 
moments  it  was  thought  by  myself  and  others,  that  he  would 
certainly  die.  This  patient,  however,  would  probably  suffer  in 
the  same  way  from  any  surgical  procedure.  After  his  recovery 
he  told  me  that  he  had  once  fainted  in  the  same  alarming  way 
on  calling  upon  a  surgeon  who  proposed  to  make  some  kind  of 
an  examination.  Faintness,  vertigo,  and  nausea  are  also  some- 
times produced  even  by  gentle  syringing  of  the  ear.  Yet,  if  the 
proper  method  is  practised,  and  the  proper  care  as  to  gentleness 
be  taken,  it  is  not  one  case  in  a  hundred  in  which  any  unpleasant 
symptoms  will  occur.  Simple  a  procedure  as  it  is,  the  proper 
method  must  first  be  learned.  The  water  should  be  warmed ;  it 
should  be  injected  into  the  concha  before  it  is  allowed  to  pass 
into  the  auditory  canal — in  short,  until  you  know  your  patient, 
you  should  alwa'ys  proceed  very  slowly  and  gently  with  the  syr- 
inge, especially  in  the  removal  of  pus. 

But,  in  spite  of  all  these  drawbacks,  none  of  which  I  would 
underrate,  I  believe,  as  an  outcome  of  twenty  years'  active  ex- 
perience in  aural  disease,  that  it  remains  the  best  means,  on  the 
whole,  in  by  far  the  largest  number  of  cases  of  cleansing  the  ear. 
I  cannot  think  that  the  use  of  warm  water  to  the  ear  thoroughly 
and  often  is  any  more  dangerous,  but,  on  the  contrary,  of  the 
same  amount  of  good  as  the  use  of  the  same  agent  in  the  same 
way  in  cleansing  fistulous  ulcers,  open  cavities,  and  other  parts 
of  the  body  which  may  from  time  to  time  become  filled  with 
pus.  I  see  no  argument  in  the  reasoning  that,  because  warm 
water  may  soften  the  tissue,  its  use  should  be  avoided  for  the 
purpose  of  cleansing  a  cavity  which  requires  it.  The  best  syr- 
inge which  I  have  ever  seen  is  one  to  be  procured  in  Paris  of 
Liier,  which  has  not  come  into  general  use,  which  we  are  using 

1  Diseases  of  the  Ear,  by  A.  H.  Buck, 'p.  232. 
s  Archives  of  Otology,  vol.  ix.,  p.  16. 


METHOD   OF   CLEANSING  TYMPANUM.  453 

in  the  Manhattan  Eye  and  Ear  Hospital,  and  which  I  am  using 
in  my  private  practice  with  great  satisfaction.  It  is  called  the 
reservoir  syringe  (see  page  132),  and  it  is  filled  without  any  motion 
of  the  piston,  so  that  the  one  action  required  is  the  discharge  of 
its  contents  into  the  ear.  On  the  withdrawal  of  the  piston  it 
fills  itself  perfectly.  The  India-rubber  syringes  sold  in  the  shops 
will  do  very  well  for  patients  to  use  in  cases  of  short  duration  ; 
in  chronic  cases  a  good  metallic  syringe  is  required.  The  foun- 
tain syringe  is  valuable  where  prolonged  irrigation  is  required, 
as  is  also  Fayette  Taylor's  douche.  But  for  ordinary  use  the  pis- 
ton syringe,  made  of  metal,  is  the  preferable  one  for  the  purpose 
of  removing  discharges  from  the  ear. 

Unless  the  practitioner  has  had  a  large  experience  in  cleans- 
ing ears,  he  should  avoid  the  use  of  a  syringe  whose  nozzle  is 
long  enough  and  sufficiently  slender  to  enter  the  auditory  canal 
as  far  as  the  junction  of  the  bony  with  the  cartilaginous  portion. 
Th*e  slightest  unexpected  movement  of  the  patient  while  the 
syringe  is  used,  may  cause  great  harm  to  the  lining  membrane 
of  the  canal. 

There  are  several  methods  of  cleansing  ears  affected  with 
a  chronic  suppurative  process.  That  which  I  usually  adopt 
is  a  combination  of  the  suggestions  of  Politzer,  Hinton,  and 
Schwartze.  It  is,  I  think,  a  simple  method,,  and  capable  of  be- 
ing fully  carried  out  by  any  practitioner,  but  not  by  the  patient 
or  a  nurse.  The  personal  care  and  supervision  of  a  medical 
man,*  are  necessary  to  the  successful  treatment  of  any  case  of 
chronic  suppuration  in  the  ear.  This  personal  care  need  not 
always  be  daily,  although  it  is  better  to  have  it  so ;  but  it  should, 
at  the  very  least,  be  given  twice  a  week,  while  the  attendant  of 
the  patient  is  instructed  as  well  as  may  be,  for  the  performance 
of  the  duty  of  cleansing  the  ear  in  the  intervening  time.  The 
importance  of  the  cases  for  which  the  daily  attendance  of  the 
physician  is  required,  if  properly  set  forth,  will  do  away  with 
any  objections  that  may  be  made.  No  one  certainly  would  ob- 
ject to  the  daily  attendance  of  a  physician  upon  a  case  of  sup- 
puration of  the  cornea,  and  I  submit  that  a  suppuration  in  the 
cavity  of  the  tympanum  and  membrana  tympani  is  of  equal  im- 
portance, with  the  disease  of  the  organ  of  vision. 

The  method  :  The  ear  is  first  carefully  cleansed  with  luke- 
warm water  by  means  of  a  good  syringe.  The  bowl  to  contain 
the  water  coming  from  the  ear,  should  be  held  by  the  patient  him- 
self— unless  a  very  young  child  be  the  subject — and  be  pressed 
well  into  the  glenoid  fossa,  when  no  water  will  be  spilled.  After 
this  the  ear  is  filled  with  lukewarm  water  poured  from  a  test- 
tube,  a  spoon,  or  the  like,  and  the  meatus  carefully  stopped  by 


454  CLEANSING-. -THE  TYMPANUM. 

a  bit  of  cotton- wool.  The  Eustachian  tube  is  then  inflated  by 
means  of  Politzer  s  method,  and  to  such  an  extent  that  a  few 
drops  of  the  water  are  forced  by  the  side  of  the  cotton  out  of  the 
canal.  This  is,  of  course,  conclusive  evidence  that  the  air  has 
been  forced  through  the  tube  into  the  middle  ear,  and  through 
the  hole  in  the  drum-head  into  the  external  canal.  The  ear  is 
again  carefully  syringed  and  examined  by  the  surgeon. 

A  long  slender  pipette,  or  Hartmamr  s  tympanic  syringe,  are 
•  sometimes  necessary  to  clean  a  tympanic  cavity  that  is  not  well 
exposed  because  the  hole  in  the  drum-head  is  small.  The  curette 
will  sometimes  be  necessary  also,  in  order  to  cleanse  the  tym- 
panum from  inspissated  pus. 

Sometimes  the  use  of  the  piston  syringe  is  not  well  borne  by 
the  patient,  the  shock  of  the  water  being  too  great.  In  such 
cases  the  fountain  syringe  should  be  used.  Instead  of  the  thin 
bowl,  that  I  have  recommended  as  a  receptacle  for  the  fluid  that 
comes  from  the  canal,  after  having  been  injected,  some  practi- 
tioners use  a  vessel  such  as  depicted  in  the  accompanying  cut — 


FIG.  96.— Vessel  used  in  Syringing  the  Ear. 

the  "  Eiterbecher  "  of  the  Germans.  It  is  certainly  very  con- 
venient  on  account  of  the  fact  that  it  adapts  itself  so  well  to  the 
glenoid  fossa,  but  it  is  not  deep  enough  if  any  prolonged  syring- 
ing is  required.  Then  the  bowl  will  do  better,  and  on  the  whole 
I  think  it  is  to  be  preferred. 

I  have  known  sad  cases,  where  parents,  in  obedience  to  their 
medical  adviser,  have  faithfully  syringed  the  ears  of  a  child 
suffering  from  chronic  suppuration  for  years,  but  where  the 
parts  have  not  been  perhaps  even  once,  thoroughly  cleansed. 
Exuberant  granulations  or  polypi  had  sprung  up,  bony  growths 
had  occurred,  which  are  positive  evidences  of  the  imperfect 
removal  of  pus  and  other  hurtful  material. 

After  the  syringing,  the  parts  should  be  dried  by  the  use  of 
absorbent  cotton  twisted  about  a  bit  of  wood,  or  a  wire  cotton- 
holder,  very  carefully  applied,  with  the  aural  mirror  on  the  fore- 
head, so  that  both  hands  are  free.  For  self-evident  reasons,  it 
would  never  be  proper  to  leave  fluid  in  a  cavity  upon  which 
medication  is  about  to  be  applied.  After  you  have  secured 
thorough  cleansing  of  the  ears,  I  believe  medication  is  of  second- 


REMOVAL   OF   GRANULATIONS. 


455 


ary  importance.  Wilde's  snare  and  Buck's  curettes  are  the  best 
instruments  for  removing  polypi  where  instrumental  interfer- 
ence becomes  necessary. '  Nothing  will  keep  up  a  discharge  of 
pus  from  the  ear,  so  persistently  as  a  small  polypus  or  granula- 
tion. My  experience  is  exactly  the  same  as  that 
of  Troltsch,  published  in  his  treatise  on  the  ear, 
in  the  first  edition  of  1862,  where  he  states  that 
he  has  often  seen  a  discharge  of  very  long  stand- 
ing disappear,  as  in  the  twinkling  of  an  eye,  on 
the  removal  of  a  small  growth.  I  think  the  cu- 
rettes should  be  made  with  sharp  edges  —  not 
blunt,  as  first  sold  in  the  shops.  The  profession 
is  very  much  indebted  to  Buck  and  Politzer,  for 
the  suggestion  of  these  very  useful  instruments 
for  cleaning  out  the  tympanic  cavity  and  audi- 
tory canal.  I  hardly  know  how  I  would  get  on 
without  them,  after  having  enjoyed  their  use  for 
some  years.  Pedunculated,  granulations  and 
polypi,  should  be  removed  as  one  of  the  first 
steps  in  any  continued  treatment.  Granulations 
with  a  broad  base  are  very  troublesome,  it  be- 
ing very  difficult  to  remove  them  thoroughly, 
even  when  the  patient  is  under  observation  for 
a  long  time.  It  is  often  necessary  to  etherize 
the  patient  in  order  to  free  the  tympanic  cavity 
from  granulations.  The  great  prerequisite  hav- 
ing been  accomplished,  of  securing  a  free  tym- 
panic cavity,  the  question  then  is,  What  agent 
shall  we  choose  for  the  cure  of  the  diseased 
membrane,  and,  consequently,  for  stopping  the 
discharge  ?  A  very  great  deal,  of  late,  has  been 
said  about  the  so-called  dry  treatment  of  suppu- 
ration of  the  middle  ear.  There  was  a  famous 
peripatetic  quack  who  practised  a  dry  treatment 
which  was  peculiarly  successful.  He  was  in  the 
habit  of  pouring  in  plaster-of-Paris,  for  the  cure 
of  long-existing  discharge  of  pus  from  the  ear, 
and  the  cure  for  a  time  was  effectual.  Much  of  the%so-called 
dry  treatment  of  to-day,  will  in  some  cases  be  as  disappoint- 
ing as  was  its  prototype.  The  treatment  by  powders  is,  not 
particularly  new,  however.  The  late  Mr.  James  Hinton  was 
very  much  in  the  habit  of  using  French  chalk  and  other  pow- 
ders, and  my  former  assistant,  Dr.  F.  H.  Rankin,  of  Newport, 
recommended  iodoform  in  diseases  of  the  ear,  in  an  article  pub- 
lished in  the  New  York  Medical  Journal,  some  time  after  he  had 


FIG.  97.— Buck's 
Pipette. 


456  SOLUTIONS   AND   POWDERS. 

successfully  used  it  in  the  Manhattan  Hospital.  Agnew,  and 
Rider,  and  other  authorities  have  long  used  powdered  alum. 
Treatment  by  powders  is  not,  therefore1,  a  new  subject,  although 
some  agents,  boracic  acid  in  particular,  have  been  used  only 
lately.  In  spite  of  all  the  claims  for  the  exclusive  use  of  pow- 
ders, in  the  treatment  of  the  ear,  and  valuable  as  is  their  place 
in  our  therapeutic  resources,  I  still  think  that  instillations  of 
fluids  hold  the  first  rank,  and  that  the  use  of  powders  is  of  sec- 
ondary value.  Whatever  may  be  thought  of  this  view,  it  isj  I 
think,  indisputably  sound  doctrine  that  cleansing  must  precede 
the  use  of  any  agents,  and  that  thorough  cleansing  is  impossible, 
in  many  cases,  without  the  use  of  the  syringe. 

For  the  healing  of  a  diseased  mucous  membrane  that  has  for 
some  weeks  or  months  secreted  pus,  and  which  is  free  from 
polypi  or  large  granulations,  I  would  advise  that  fluid  applica- 
tions be  first  tried.  In  my  practice  I  use  sulphate  of  zinc,  from 
one  to  four  grains  to  the  ounce ;  sulphate  of  alum  in  the  same 
proportion.  Nitrate  of  silver  I  use  usually  upon  a  cotton-holder, 
from  five  to  sixty  grains  to  the  ounce,  or  from  a  long,  slender 
pipette  adapted  to  the  middle  ear,  (see  Fig.  97)  in  the  weak 
solutions.  If  a  strong  solution  of  nitrate  of  silver  be  used,  it 
should  be  at  once  neutralized  with  salt  and  water.  I  also  use 
alcohol,  as  suggested  by  Lowenburg,  of  Paris,  especially  in  cases 
where  the  tissue  is  granular.  A  preparation  of  resorcin  in  cases 
where  the  mucous  discharge  exceeds  the  purulent,  is  also  useful. 
Boracic  acid  in  solution  seems  to  me  to  accomplish  very  little. 
It  is,  indeed,  difficult  to  say  which  are  the  best  astringents.  But 
some  cases  do  well  with  any  of  the  ordinary  astringents,  and 
some  never  cease  to  be  the  seat  of  the  formation  of  pus,  no  mat- 
ter how  long,  how  carefully  you  treat  them,  and  what  agents 
you  may  use.  Carbolic  acid  and  permanganate  of  potassium 
have  proved  worse  than  useless  in  my  hands. 

When  solutions  do  not  act  well  or  promptly,  powders  may  be 
resorted  to.  lodoform  is  valuable  in  some  cases.  My  associate, 
Dr.  Ely,  thinks  it  especially  useful  in  those  cases  where  the 
tissues  are  pallid  and  have  an  indolent  appearance.  Well-trit- 
urated boracic  acid  is  also  a  useful  agent,  but  it  is  by  no  means 
a  panacea,  no  matter  how  it  is  applied,  or  with  whatsoever  com- 
binations. There  are  objections  to  powders  which  at  once  sug- 
gest themselves  when  their  use  is  advocated  in  treating  diseased 
mucous  membranes,  like  those  of  the  nose  or  middle  ear.  They 
are  not  always  absorbed,  and  they  sometimes  leave  a  trouble- 
some, irritating  mass  behind.  Then  they  occasionally  impair 
the  hearing  by  mechanically  obstructing  the  passage  of  the 
sound  waves.  While  a  solution  is  poured  into  the  ear,  and  in 


SOLUTIONS   AND   POWDERS.  457 

from  five  to  ten  minutes  that  which  is  not  absorbed  may  be  al- 
lowed to  run  out,  the  powder  must  remain  until  the  ear  is  again 
cleansed,  which  is  not  for  hours.  A  tube  made  from  a  quill,  or 
one  of  the  powder-blowers  especially  invented  for  the  purpose, 
do  equally  well  for  forcing  the  powder  into  the  canal  of  the  tym- 
panic cavity.  I  do  not  employ  large  masses  of  the  powder — sim- 
ply enough  to  give  the  ulcerated  or  carious  portion  a  good  coating. 
Solutions  are  usually  much  better  tolerated  by  the  ear  when 
they  are  warm.-  A  lighted  gas-burner,  the  flame  of  a  candle,  a 
bowl  of  hot  water,  are  all  convenient  means  for  heating  the 
solution  which  is  to  be  used.  When  powder  is  employed,  the 
mirror  should  be  used  from  the  forehead,  so  that  one  may  know 
just  where  it  has  gone,  and  renew  th£  application  if  not  enough 
is  applied. 


FIG.  98.— Knapp's  Powder-Blower. 

Whatever  may  be  said  in  favor  of  certain  specifics,  used 
either  as  powders  or  solutions,  certain  cases  of  suppuration  of 
the  middle  ear  will  remain  uncured  in  hands  never  so  skilful. 
They  are,  from  their  nature  or  their  environment,  incurable.  A 
case  of  long-standing  ulceration  in  the  tympanic  cavity  and  mas- 
toid  is  almost  certain  to  involve  more  or  less  superficial  death 
of  the  bone.  When  there  is  dead  bone  that  cannot  properly 
be  removed  by  instruments,  solutions  of  dilute  mineral  acids, 
nitric  acid  and  sulphuric — one-quarter  to  one-half  per  cent. — 
dropped  into  the  ear  twice  a  day  (Dr.  Urban  Pritchard)  will  be 
serviceable.  An  error  in  treatment,  an  injudicious  mode  of  life, 
an  undue  exposure  to  wet  and  cold,  may  at  any  time  cause  the 
smoldering  disease  to  blaze  into  a  condition  that  is  fatal  to  life. 
Pyaemia,  meningitis,  and  cerebral  abscess  are  by  no  means  the 
infrequent  ending  of  some  of  those  cases.  He  who  has  found  a 
panacea  for  all  of  them,  is  in  a  state  of  mind  far  removed  from  a 
scientific  consideration,  of  the  conditions  which  are  to  be  found 
in  chronic  suppuration  of  the  middle  ear. 

When  it  is  said  that  "a  moist  treatment  of  otorrhcea  in  many 
instances  has  a  tendency  to  keep  up  rather  than  to  check  the 
morbid  discharge  from  the  ear," '  if  by  this  language,  it  is  meant 
that  careful  cleansing  of  a  suppurating  middle  ear  with  warm 
water,  and  the  subsequent  instillation  of  solutions,  is  in  many 
instances  a  bad  surgical  method,  I  can  only  answer  that  this 
statement,  according  to  my  experience,  is  not  borne  out  by  facts. 

1  Burnett:  American  Journal  of  the  Medical  Sciences,  January,  1883. 


458  GRANULATIONS   AND   POLYPI. 

The  presence  of  granulations  and  polypoid  growths  does  not,  in 
my  opinion,  centra-indicate  the  use  of  warm  water.  Their  pres- 
ence does  indicate,  however,  a  necessity  for  their  removal,  either 
by  the  snare,  the  forceps,  or  caustics,  pari  passu  with  the  con- 
stant cleansing  process.  Over  and  over  again,  however,  have  I 
seen  growths  shrivel  and  disappear,  before  the  operator  was 
ready  to  remove  them  by  cutting  or  twisting  instruments  or  by 
caustics,  under  the  simple  plan  of  cleansing  the  ear  with  warm 
water. 

I  think  it  important  to  inflate  the  ears  very  frequently,  from 
two  to  four  times  a  week,  and  sometimes  daily,  by  means  of 
Politzer's  method,  during-  the  treatment  of  chronic  suppura- 
tion of  the  middle  ear.  The  current  of  air  is  useful  to  dislodge 
inspissated  pus  or  tenacious  mucus,  and  it  assists  materially  in 
the  essential  preliminary  of  all  applications  ;  that  is,  a  complete 
removal  of  the  pus.  Sometimes  exhaustion  of  the  air  from  the 
tympanum  by  Siegle's  otoscope  aids  in  getting  the  cavity  clean. 
An  ordinary  air-bag  may  also  be  used  for  this  purpose.  Those 
cases  in  which  there  is  a  constant  accumulation  of  long  strings 
of  very  tenacious  mucus,  with  very  little  pus,  are  exceedingly 
difficult  to  manage.  The  cause  for  this  is  to  be  found  in  the  ex- 
cessive catarrh  of  the  naso-pharyngeal  space,  and  of  the  Eusta- 
chian  tube,  which  usually  accompanies  this  condition  of  the 
tympanic  cavity.  The  mucus  is  so  tenacious  in  these  cases  that 
not  even  the  syringe  or  the  cotton-holder  will  remove  it,  but  the 
forceps  must  be  resorted  to.  Of  course,  fundamental  treatment 
will  begin  at  the  fons  et  origo,  of  the  disease  of  the  middle  ear, 
that  of  the  nose  and  throat.  I  need  hardly  say  that  the  general 
condition  is  to  be  most  carefully  considered  in  all  cases  of  chronic 
local  disease.  The  practitioner  will  often  find  much  to  do  in  this 
direction,  in  these  cases  of  chronic  suppuration  of  the  ear.  The 
restoration  of  a  perforated  drum-head  is  a  most  interesting  re- 
parative  process.  The  ease  and  rapidity  with  which  they  heal 
in  recent  cases  is  startling,  and  even  in  chronic  cases,  we  are 
sometimes  agreeably  surprised  to  see  how  soon  a  membrana 
tympani  is  restored,  after  simple  cleansing  of  the  middle  ear  has 
been  maintained  for  a  few  weeks. 

The  caustics  which  I  use  for  removing  granulations,  are  fum- 
ing nitric  acid  and  chromic  acid,  as  well  as  solutions  of  nitrate 
of  silver,  from  twenty  to  sixty  grains  to  the  ounce.  Alcohol  is 
also  valuable.  When  alcohol  is  employed  it  should  be  used  at 
least  twice  a  day,  and  warmed  before  it  is  poured  in  the  ear. 
The  application  is  painful  for  a  few  instants  only.  I  usually 
cause  the  granulations  to  bleed  freely,  by  puncturing  them  with 
a  cataract-needle,  before  applying  the  caustics. 


SKIN   GRAFTING. 

Burnett '  thinks  that  zinc-drops,  may  supply  something  which 
makes  the  bottom  of  the  auditory  canal  favorable  to  the  growth 
of  the  aspergillus  or  aural  fungus.  As  proof  of  this,  is  adduced 
the  fact  that  a  fungus  is  sometimes  found  in  zinc  solutions  that 
have  been  imperfectly  stoppered.  All  the  harm  that. fungi  in 
zinc  or  other  solutions  can  probably  accomplish,  is  to  weaken 
the  solution.  I  consider  this  objection  to  zinc,  or  other  solutions 
.  as  unsubstantiated  as  yet  by  any  facts,  and  doubtful  even  from 
a  theoretical  point  of  view,  for  it  is  improbable  that  the  fungus 
would  be  poured  into  the  ear,  but  that  portion  of  the  solution 
which  is  clear.  Besides,  before  the  growths  were  established, 
the  next  good  syringing  with  warm  water  would  be  an  efficient 
parasiticide  if  any  were  necessary. 

In  June,  1878,  Dr.  Edward  T.  Ely,*  my  associate  in  private 
practice,  made  use  of  skin  grafting  in  the  treatment  of  chronic 
suppuration  of  the  middle  ear.  Dr.  Ely  continued  this  practice 
in  nine  cases  occurring  among  our  patients,  and  I  have  repeated 
his  experiments.  This  method  of  treatment  is  especially  indi- 
cated for  cases  where  we  cannot  expect  a  restoration  of  the  mem- 
brane and  a  cessation  of  the  discharge  by  the  ordinary  treat- 
ment. The  results  obtained  have  not  been  brilliant,  but  in  two 
cases  a  substantial  gain  in  the  condition  of  the  tympanic  cavity 
was  secured. 

This  operation  is  available  in  cases  where  the  membrana 
tympani  is  nearly  gone,  and  where  the  discharge  is  at  times 
considerable,  but  which  at  other  times  ceases.  The  ear  is  first 
carefully  dried,  and  after  due  care  has  been  taken  that  all  the 
instruments  to  be  used,  as  well  as  the  hands  of  the  surgeon  and 
his  assistant,  are  scrupulously  clean,  a  small  bit  of  integument 
is  removed  from  the  arm  of  the  patient. 

It  is  carefully  soaked  in  a  solution  of  boracic  acid,  and  ap- 
plied by  means  of  a  cotton-holder,  silver  probe,  or  Politzer's 
eyelet  forceps  to  the  exposed  surface  of  the  tympanic  cavity. 
As  many  as  three  or  four  grafts  may  be  applied.  The  canal  is 
then  gently  packed  with  absorbent  cotton,  and  the  patient  is 
advised  to  be  very  careful  to  avoid  active  exercise,  riding  in 
wagons,  stages,  or  other  conveyances,  in  which  there  is  much 
motion,  for  two  or  three  days.  The  grafts  may  be  examined  in 
three  or  four  days.  If  union  has  occurred  the  packing  should 
be  continued  for  a  few  days  longer.  I  think,  from  personal  ex- 
perience, that  this  method  of  treatment  will  be  of  service  in  a 
limited  class  of  cases,  where  an  occasional  period  of  suppuration 


1  American  Journal  of  the  Medical  Sciences,  January,  1883. 
*  Archives  of  Otology,  vol.  ix.,  p.  343. 


460  SKIN   GRAFTING — NITRATE   OF   SILVER.       - 

occurs  in  a  largely  exposed  tympanic  cavity,  over  which  the 
drum-head  cannot  be  made  to  heal  by  ordinary  means,  and 
where  the  discharge  of  pus  only  occurs  at  intervals,  for  ex- 
ample, during  a  coryza.  If  the  grafts  do  not  completely  cover 
the  exposed  tympanic  cavity,  they  may  diminish  the  secreting 
surface. 

Berthold,  in  August,  1878,  two  months  after  Ely's  cases,  per- 
formed myringoplasty  '  in  two  cases.  The  perforations  healed, 
apparently  as  the  result  of  a  new  inflammation  set  up  by  the 
manipulations  and  by  the  adhesion  of  a  portion  of  the  graft 
which  became  a  portion  of  the  new  tissue.  Berthold  put  a  piece 
of  court-plaster  upon  the  drum  membrane,  which  he  allowed  to 
remain  there  three  days.  The  object  of  this  was  to  remove  the 
epithelium.  The  drum-head  was  found  to  be  closed  on  the 
twentieth  day.  In  a  second  case,  also,  a  perforation  was  healed 
by  this  method.  C.  U.  Tangeman,  has  also  published  an  inter- 
esting case  of  reproduction  of  the  membrana  tympani  by  skin 
grafting.  He  denuded  the  edges  of  the  perforation  and  put  in 
a  piece  of  skin  from  the  arm  of  the  patient,  and  retained  it  in 
position  by  collodion.  The  drum-heads  were  not  entirely  closed, 
but  nearly  so.2 

In  Schwartze's  paper  calling  attention  to  the  use  of  the 
nitrate  of  silver,  in  what  he  regards  as  strong  solutions,  he 
advises  against  the  instillation  of  nitrate  of  silver  where  gran- 
ulations or  disease  of  the  bone  exists.  His  exact  words  are  : 
"The  caustic  treatment  only  promises  a  nearly  certain  result, 
when  we  may  exclude  with  positiveness  the  existence  of  gran- 
ulations upon  the  exposed  mucous  membrane,  or  upon  the 
remains  of  the  membrana  tympani,  and  when  there  are  no 
evidences  of  ulceration  of  the  bone." ; 

The  experience  of  American  otologists  has  been  that  strong 
solutions  of  nitrate  of  silver  may  be  safely  and  profitably  used, 
even  where  there  are  granulations  and  polypi.  Indeed,  I  would 
especially  recommend  it  for  some  of  these  cases,  although  I  ad- 
mit that  their  value  is  often  strikingly  seen  in  obstinate  cases 
of  chronic  suppuration,  where  the  membrane  is  not  yet  in  what 
may  be  termed  a  very  proliferous  condition. 

An  efficient  method  of  applying  nitrate  of  silver  to  the  whole 
mucous  tract  of  the  middle  ear,  at  least  to  the  lining  of  the 
cavity  of  the  tympanum  and  the  Eustachian  tube,  is  the  follow- 
ing :  The  solution  is  dropped  into  the  cavity  of  the  tympanum 

1  Monatsschrift  fur  Ohrenheilkunde,  November,  1878.  From  Vortrag  in  Natur- 
forscher  Sammlung.  CaSsel,  1878. 

•  Archives  of  Otology,  vol.  xii. ,  p.  228. 

3  Archiv  f iir  Ohrenheilkunde,  Bd.  IV. ,  p.  2. 


CLEANSING   THE  TYMPANUM.  461 

through  the  external  meatus,  and  then  forced  through  into  the 
tube  by  two  or  three  puffs  from  the  ordinary  air-bag  used  in 
Politzer's  method.  Of  course  the  patient  will  taste  the  nitrate 
of  silver,  if  it  be  used  in  this  manner. 

Mr.  James  Hinton,  of  London,  recognizing  the  fact  upon 
which  I  have  laid  so  much  stress,  that  thorough  cleansing  of 
the  ear  is  the  first  requirement  of  all  treatment  of  chronic  sup- 
puration in  this  part,  advises  the  forcible  syringing  of  the  tym- 
panic cavity,  by  means  of  a  syringe  whose  nozzle  is  made  to  fit 
into  the  external  meatus,  so  as  to  exclude  all  the  external  air. 
He  also  syringed  the  tympanic  cavity  through  the  Eustachian 
tube,  and  used,  both  for  this  external  and  internal  syringing, 
solutions  of  carbonate  of  soda,  say  of  twenty  grains  to  the 
ounce.  I  believe  this  latter  method  of  washing  out  the  cavity 
of  the  tympanum,  was  revived  and  applied  to  cases  of  suppura- 
tion by  Dr.  Millinger,  of  Vienna.  I  have  found  the  washing 
out  of  the  middle  ear,  with  the  solution  of  soda,  a  very  useful 
adjuvant  in  these  obstinate  cases  now  under  consideration  ;  for 
it  must  always  be  borne  in  mind,  if  we  would  avoid  great  dis- 
appointment, that  these  cases  are  usually  obstinate,  and  often 
trying  to  the  patience  of  the  practitioner.  I  cannot  say  very 
much  for  the  method  of  forcing  fluid  into  the  auditory  canal, 
with  the  nozzle  of  the  syringe  placed  hermetically  into  the 
meatus.  I  sometimes  resort  to  it ;  but  I  have  usually  found  it 
rather  violent  in  its  action,  as  it  is  apt  to  cause  dizziness  and 
vertigo. 

Instead  of  washing  out  the  canal  with  a  solution  of  bicarbo- 
nate of  soda,  I  think  it  much  better  to  cause  the  patient  to  drop 
in  a  solution  of  say  twenty  grains  to  the  ounce,  once  or  twice  a 
day.  After  this  has  had  the  effect  of  softening  inspissated  pus, 
the  ear  may  be  syringed  with  warm  water. 

It  is  necessary  and  proper,  in  some  cases  that  have  resisted 
less  active  treatment,  to  apply  the  solid  nitrate  of  silver  to  the 
edges  of  the  perforated  membrana  tympani,  as  well  as  to  the 
tympanic  cavity.  It  is  best  applied  on  a  probe,  upon  the  point 
of  which  it  has  been  fused,  in  a  platinum  cup  placed  over  a 
lighted  lamp  or  gas-burner.  This  treatment,  unlike  the  others, 
is  apt  to  cause  pain,  which  usually  passes  away  on  pouring 
warm  water  into  the  ear.  It  is  a  method,  however,  only  to  be 
resorted  to  when  other  means  fail. 

As  has  been  before  said,  the  cleansing  of  the  ear  by  the 
medical  attendant,  should  be  performed  about  three  times  a 
week.  If  the  suppuration  be  profuse,  the  patient  should  be  seen 
daily.  Here,  as' in  other  departments  of  otology,  we  meet  with 
great  prejudice  on  the  part  of  the  laity.  They  have  been  so 


462          CHRONIC  SUPPURATION— TREATMENT. 

accustomed  to  be  sent  off  with  a  prescription  for  a  "running 
from  the  ear,"  that  they  are  amazed  at  being  asked  to  come  to 
the  office  daily,  or  three  times  a  week.  Yet  this  will  often  be 
necessary,  and  here  as  elsewhere  there  remains  some  pioneer 
work  to  be  done  in  the  education  of  the  people. 

Many  cases  of  chronic  suppuration  of  the  middle  ear  are  not 
cured  because  the  treatment  is  carried  on  by  the  patient  himself 
or  by  his  friends.  Very  few  persons  are  capable  of  thoroughly 
cleansing  their  own  ears.  No  one  is  capable  of  thoroughly 
cleansing  the  ear  of  another  unless  a  special  training  for  this 
object  has  been  undergone.  In  fact,  a  successful  treatment  of 
these  cases  requires  the  care  of  a  physician.  It  is  easier  to  learn 
to  clean  and  dress  an  ordinary  bone  fistula,  than  to  learn  to  re- 
move the  secretions  from  an  inflamed  tympanic  cavity  and 
mastoid  cells.  He  who  would  bring  his  cases  to  a  successful 
ending,  must  himself  bear  the  brunt  of  the  labor  of  treatment. 
It  cannot  be  given  over  to  inexperienced  hands.  Whenever  this 
personal  care  o.f  the  physician  is  not  to  be  obtained  for  these 
chronic  cases,  only  approximately  good  results  are  possible.  I 
have  sometimes  been  able  to  train  a  nurse  or  relative  of  the 
patient,  so  that  quite  thorough  cleansing  is  effected. 

Besides  all  this,  each  case  should  be  considered  by  itself .  Some 
cases  will  tolerate  thorough  cleansing  by  the  syringe,  cotton- 
holder,  and  curette,  while  others  will  resent  all  but  the  most  deli- 
cate handling,  by  fits  of  vertigo,  fainting,  and  inflammatory  reac- 
tion, so  that  a  case  must  be  studied  for  a  few  days  before  it  can 
be  definitely  determined  as  to  how  much  and  what  is  to  be  done. 

Dr.  G.  M.  Beard '  thought  that  the  galvanic  current  was 
sometimes  a  powerful  adjuvant  in  healing  a  suppurative  pro- 
cess in  the  middle  ear,  just  as  it  is  in  healing  ulcers  in  other 
parts  of  the  body.  An  electrode  with  a  long  narrow  extremity, 
covered  with  a  little  cotton,  is  passed  into  the  auditory  canal 
through  a  rubber  speculum.  The  canal  is  usually  filled  with 
warm  water.  The  electrode  is  connected  with  the  negative  pole 
of  the  battery.  The  positive  pole  is  placed  either  in  the  hands 
of  the  patient  or  at  the  back  of  the  neck.  Only  very  weak  cur- 
rents and  short  applications  are  borne,  and  the  treatment  should 
be  cautiously  conducted.  Drs.  Mathewson  and  Prout,  in  con- 
junction with  Dr.  Beard,  tested  this  plan  of  treatment  in  cases 
^at  the  Brooklyn  Eye  and  Ear  Hospital.  The  character  of  the 
discharge  soon  begins  to  change  under  this  treatment,  and  in 
some  cases  the  cure  seems  to  have  been  more  speedy  than  it 
would  have  been  without  it. 

J  Verbal  communication. 


CHRONIC  -SUPPURATION — TREATMENT.  463 

In  cases  of  chronic  suppuration  of  the  tympanic  cavity, 
where  the  opening  in  the  drum-head  is  very  small,  or  when 
from  any  other  reason  it  is  very  difficult  to  thoroughly  remove 
the  pus,  I  have  found  benefit — in  connection  with  the  use  of 
Politzer's  method  of  inflation — from  the  use  of  Siegle's  otoscope 
attached  to  a  syringe,  for  the  purpose  of  sucking  out,  as  it  were, 
the  fluids  from  the  drum-cavity.  After  all  the  other  means  of 
cleansing  the  part  have  been  thoroughly  used,  it  will  still  be 
sometimes  found  that  more  pus  may  be  evacuated  by  the  suc- 
tion method. 

Hartmann's  tympanic  syringe,  which  has  been  mentioned  on  one  of  the  pre- 
ceding pages,  is  often  useful  in  cleansing  the  tympanum.  It  consists  essentially 
of  a  silver  tube  2£  mm.  in  circumference  and  7  cm.  long.  Each  extremity  is 
curved,  the  one  for  the  tympanum  at  a  right  angle  ;  the  curved  portion  is  about 
one  mm.  long.  The  distal  end  of  the  tube  is  curved  at  an  obtuse  angle,  and 
has  somewhat  of  a  funnel-shaped  orifice,  to  which  a  bit  of  rubber  tubing  is  at- 
tached. The  tubing  should  be  as  delicate  as  possible,  so  that  its  weight  may 
not  interfere  with  the  position  of  the  tube  in  the  tympanum.  The  water  is  in- 
jected by  means  of  a  Davidson  syringe,  affixed  to  the  rubber  tubing. 

Dr.  C.  I.  Pardee1  believes  that  the  choice  of  an  astringent 
may  be  regulated  by  the  character  of  the  secretion.  If  the  se- 
cretion from  the  exposed  tympanic  cavity  be  predominantly  of 
a  mucous  character,  Dr.  Pardee  uses  nitrate  of  silver.  When 
the  secretion  is  chiefly  purulent,  he  uses  weak  astringents  of 
sulphate  of  zinc,  acetate  of  lead,  and  alum.  It  would  certainly 
be  a  great  advance  did  we  have  more  certain  indications  for  the 
use  of  strong  or  weak  astringents  ;  but  I  am  not  prepared  to 
give  a  positive  opinion  as  to  the  correctness  of  Dr.  Pardee's 
theory.  I  may  only  repeat  what  was  said  in  substance  in  the 
preceding  part  of  this  chapter,  that  any  of  the  well-known 
mineral  astringents  do  very  well,  if  the  parts  are  thoroughly 
cleansed,  and  if  none  of  the  consequences  of  the  suppurative 
process  have  as  yet  resulted.  It  should  not  be  forgotten  that 
the  pharynx  and  nostrils,  will  often  require  nearly  as  much 
treatment  as  the  ear. 

The  surgeon  who  is  in  the  frequent  habit  of  examining  the 
membrana  tympani  will  find  many  cases  that  show  how  easily 
an  ulcerated  drum-head  will  sometimes  heal  under  very  simple 
or  very  crude  treatment.  Cicatricial  drum-heads  are  a  verjr 
common  experience  in  the  aural  surgeon's  observations.  A  little 
study  of  the  history  of  these  cases  shows  that  in  very  many  in- 
stances they  were  healed  when  they  were  being  treated  with 
what  we  should  term  neglect.  All  this  should  teach  us  to  be 

1  Transactions  of  the  American  Otological  Society,  Fourth  Annual  Meeting,  1871. 


464          CHRONIC  SUPPURATION — TREATMENT. 

very  careful  students  of  the  healing  processes  of  Nature.  In 
our  anxiety  to  see  results  from  treatment,  let  us  remember  to 
put  ourselves  in  the  position  of  Ambroise  Pare,  whose  benedic- 
tion to  his  wounded  patient  was,  "  I  have  dressed  you,  may  God 
cure  you." 

All  cases  of  chronic  suppuration  of  the  middle  ear,  will  not 
be  cured  even  by  good  treatment  and  favorable  conditions, 
while  here  and  there,  we  are  surprised  to  find  that  some  un- 
promising cases  do  very  well,  even  under  bad  circumstances 
and  with  no  thorough  treatment.  To  expect  too  much  from 
treatment,  to  do  too  much,  is  to  be  meddlesome  in  intent  and 
action.  If  we  are  to  make  a  choice  of  evils,  it  is  better  to  be 
skeptical  and  inactive,  than  credulous  and  meddlesome. 

It  is  an  interesting  fact  that  very  few  patients'suffering  from 
phthisis  pulmonalis  ever  recover  from  a  suppuration  of  the  ear. 
Even  so  far  as  the  accumulation  of  pus  is  concerned,  no  matter 
how  long  they  may  live,  the  cough  usually  prevents  any  healing 
of  the  membrana  tympani.  I  have  one  case  under  observation — 
the  only  one  I  have  ever  seen^-where  the  discharge  and  forma- 
tion of  pus  have  ceased,  although  the  perforation  of  the  mem- 
brane does  not  close. 


REMOVAL    OF    THE    OSSICLES    IN   CHRONIC    SUPPURATION. 

All  aural  surgeons  have  observed  the  great  benefit  sometimes 
resulting  from  a  thorough  removal  of  granulations,  and  of  scrap- 
ing or  curetting  the  tympanum.  When  the  ossicles  are  necrotic, 
and  gentler  means  fail  to  correct  the  discharge,  much  less  to  stop 
it,  a  thorough  removal  of  the  ossicles  is  indicated.  Schwartze 
first  suggested  and  performed  this  operation,  but  he  is  conserva- 
tive in  recommending  its  performance,  while  Sexton  advocates 
it  very  warmly,  even  on  cases  where  it  seems  to  me  that  the 
usually  efficient  means  already  described  in  detail  should  first 
be  given  a  fair  trial.  Whatever  may  be  said  to  the  contrary, 
removal  of  the  ossicles,  and  only  the  ossicles,  with  however 
good  an  illumination,  is  not  a  very  simple  operation,  nor  one 
entirely  devoid  of  danger.  The  inconvenience  and  danger  of  a 
chronic  suppurative  aural  process  are,  however,  so  great  that 
we  are  justified  in  such  a  severe  procedure,  when  the  continuance 
•of  the  discharge  is  due  to  necrotic  bone  that  may,  under  anaes- 
thesia be  readily  removed.  No  especial  directions  are  needed  for 
such  an  operation.  The  patient  should  be  under  the  influence  of 
ether.  The  illumination  will  soon  fail  on  account  of  the  bleed- 
ing, but  in  cases  such  as  those  for  which  the  removal  of  the 
necrotic  bone  is  performed  will  suffer  no  harm  if  the  diseased 


SOLUTIONS   AND   POWDERS.  465 

membrane  be  even  very  thoroughly  scraped  in  removing  the 
bones.  To  advise  the  operation,  however,  when  we  cannot 
definitely  decide  that  the  ossicles  are  necrosed,  and  the  tissue 
granular,  before  less  radical  means  are  given  a  fair  trial,  is  un- 
wise. Thorough  scarification  of  the  bony  canal  is  sometimes  of 
great  service  in  lessening  a  chronic  inflammation  of  the  tym- 
panum. 

THE    ARTIFICIAL    MEMBRANA  TYMPANI. 

This  contrivance  is  at  times  a  valuable  means  of  treating  a 
chronic  suppurative  process  in  the  middle  ear.  We  have  al- 
ready seen  that  a  New  York  layman  was  the  actual  inventor  of 
a  substitute  for  the  natural  membrane.  This  gentleman  used  a 
bit  of  paper  moistened  with  saliva  for  this  purpose  in  his  own 
ear,  and  showed  it  to  Dr.  James  Yearsley,  of  London,  who 
seized  upon  the  idea,  and  gave  it  to  the  profession,  substituting 
cotton-wool  for  the  paper.  Besides  acting  as  an  artificial  mem- 
brane, the  cotton  plug  is  sometimes  used  as  a  means  of  treating 
a  chronic  suppurative  process  in  the  ear.  It  is  then  packed  in 


O 


PIG.  99. — Tojnbee's  Artificial  Membrana  Tympani. 

the  canal  quite  thoroughly.  When  it  is  employed  for  the  pur- 
pose of  improving  the  hearing,  having  been  slightly  moistened, 
it  is  inserted  under  inspection — that  is,  while  the  parts  are  well 
illuminated  by  the  otoscope — by  means  of  a  pair  of  forceps,  that 
should  be  very  weak  in  the  spring,  so  that  the  blades  may  come 
together  with  very  little  pressure,  or  by  a  probe.1 

The  appropriate  position  for  the  cotton,  where  it  will  improve 
the  hearing,  will  be  found,  if  it  is  to  do  any  good,  by  placing  it 
on  different  parts  of  the  exposed  tympanic  cavity,  or  the  re- 
mains of  the  drum-head,  until  the  patient  experiences  an  im- 
provement in  the  hearing  power. 

I  have  taught  a  number  of  patients  to  use  this  kind  of  a 
drum-head,  and  I  have  seen  many  others  who  have  learned  to 
use  it  from  other  physicians.  In  the  most  cases,  however, 
Toynbee's  disk  is  preferred,  as  being  easier  to  manage. 

There  has  been  quite  a  good  deal  written  of  the  cotton  pellet 
of  late.  This  may  serve  to  call  it  again  to  the  marked  attention 
of  the  profession.  Yet  nothing  essentially  new  has  been  said 
upon  the  subject,  since  Yearsley  brought  it  fully  before  the  pro- 

1  Yearslej  on  Deafness,  p.  245. 
30 


466 


ARTIFICIAL   MEMBRANA   TYMPANI. 


fession  in  his  text-book.  To  Yearsley  belongs  all  the  credit  of 
quickly  utilizing  the  strong  hint  given  him  by  the  New  York 
merchant  with  his  spill  of  paper,  and  of  suggesting  a  practical 
use  of  an  artificial  membrana  tympani.  Queerly  enough,  an- 
other New  York  merchant,  who  had  accidentally  learned  to 
improve  his  hearing  by  a  little  roll  of  paper,  without  knowing 
of  his  immortal  predecessor,  or  of  Yearsley  or  Toynbee,  con- 
sulted me  a  few  years  since. 

In  1853,  Toynbee  suggested  another  artificial  membrana  tym- 
pani, without  knowing  of  the  previous  invention.  Toynbee's 
appliance  consists  of  a  thin  disk  of  vulcanized  rubber,  in  the 
centre  of  which  is  attached  a  fine  wire  about  an  inch  long,  which 


FIG.  100. — Method  of  Inserting  Artificial  Membrana  Tympani  (Toynbee). 


terminates  in  a  little  ring,  to  enable  the  finger  to  more  readily 
grasp  it  when  its  removal  is  desired.  An  improvement  upon  the 
original  method  of  attachment  of  the  wire,  is  to  insert  it  spirally 
into  the  disk,  like  a  corkscrew  in  a  cork. 

We  can  never  tell  without  trial,  whether  the  artificial  mem- 
brana tympani  will,  or  will  not  improve  the  hearing.  Inasmuch 
as  I  am  sometimes  asked  if  an  artificial  membrana  tympani  will 
do  any  good,  if  the  membrane  be  intact,  it  may  be  as  well  to 
state,  that  it  is  only  of  service  in  cases  of  partial  or  complete 
loss  of  the  drum-head.  Von  Troltsch  relates  a  case  of  a  deaf 
judge  who  used  to  improve  his  hearing  temporarily  by  pressing 
upon  the  membrana  tympani  with  a  probe  ;  but  I  have  never 
been  able  to  increase  the  hearing  power  by  any  similar  proced- 
ure upon  an  imperforate  membrana  tympani.  The  improve- 


ARTIFICIAL  MEMBRANA   TYMPANI.  467 

ment  to  the  hearing  that  does  sometimes  occur  when  the  cotton- 
wool, or  the  membrane  of  Toynbee  is  used,  is  probably  due  to  the 
restoration  of  the  interrupted  continuity  of  the  ossicula  auditus, 
or  even  of  the  stapes  alone,  to  the  fenestra  ovalis  and  the  laby- 
rinth. Toynbee  explained  its  benefit  by  stating  that  it  occurred 
as  a  result  of  the  closure  of  the  membrane ;  but  this  has  been 
shown  to  be  an  erroneous  explanation.  Cases  have  been  seen 
where  the  perforation  was  not  closed  by  the  artificial  membrane, 
and  yet  great  improvement  to  the  hearing  resulted  from  its  use. 
When  the  patient  first  begins  to  wear  this  membrane,  it  should 
be  used  but  for  a  very  short  time  during  the  day.  It  is  always  a 
foreign  body,  and  hence  it  is  liable  to  produce  irritation  and  in- 
crease the  suppurative  process.  Lest  any  should  think  that  the 
artificial  membrane  is  not  a  practical  and  valuable  means  of  alle- 
viating some  cases,  I  may  state  that  I  have  now  under  observa- 
tion many  patients,  for  whom  I  first  introduced  the  membrane, 
who  have  worn  it  for  years,  with  uninterrupted  benefit  to  the 
hearing  power.  I  have  taught  several  other  persons  to  apply  the 
membrane,  and  with  benefit ;  but  inasmuch  as  I  have  not  seen 
them  for  a  long  time,  it  is  not  quite  certain,  although  probable, 
that  they  are  still  using  the  substitute  for  the  natural  membrane. 
I  am  in  the  habit  of  tentatively  applying  the  artificial  membrana 
tympani  in  all  old  cases  of  chronic  suppuration  in  the  middle 
ear,  when  the  loss  of  hearing  is  very  great.  If  one  ear  be  sound, 
so  that  the  hearing  for  ordinary  purposes  is  very  good,  as  it 
always  is  under  such  circumstances,  it  is  not  worth  while  to  use 
the  artificial  drum-head  for  the  diseased  ear.  An  excessive  in- 
flammatory action  in  the  remains  of  the  drum-head,  or  in  the 
middle  ear,  precludes  any  use  of  the  artificial  membrane.  The 
patient  for  whom  it  is  to  be  employed  should  also  be  an  adult,  and 
possessed  of  a  considerable  amount  of  intelligence.  It  is  not  of 
any  use  in  the  case  of  children,  or  of  unusually  heedless  or  stupid 
adults.  The  wire  to  which  the  disk  is  attached,  sometimes  be- 
comes separated  in  removing  the  membrane,  and  the  disk  of 
rubber  is  left  behind.  This  accident,  although  a  very  insignifi- 
cant one— for  the  disk  is  readily  removed  by  syringing— is  very 
apt  to  frighten  the  patient,  unless  he  has  been  previously  warned 
not  to  be  disturbed  if  such  an  accident  occur,  and  not  to  allow 
any  improper  attempts  to  remove  such  a  foreign  body. 

Various  modifications  of  Toynbee's  disk  attached  to  a  wire 
have  been  made.  Thus,  Lucae  attaches  the  disk  to  a  small 
rubber  tube.  Burkhard-Merian  uses  a  solid  piece  of  india-rubber 
instead  of  a  wire.  Politzer  makes  one  especially  to  spare  the 
poor  the  expense  of  buying  Toynbee's  disk.  A  piece  {•  ctm.  long 
is  cut  from  the  side  of  an  india-rubber  tube  2  to  3  mm.  in  thick- 


468  CHRONIC   SUPPURATION — TREATMENT. 

• 

ness,  a  hole  is  then  made  in  one  end  and  a  wire  handle  fastened 
in  it.  Politzer  also  recommends  the  use  of  an  india-rubber  tube, 
as  long  as  the  canal,  rounded  off  at  the  distal  end  and  pushed 
down  to  the  remains  of  the  drum-head.  In  cases  in  which  the 
sides  of  the  stapes  bone  have  been  destroyed,  Politzer  has  also 
attached  a  stapes  bone  taken  from  a  dead  body  to  Toynbee's 
disk,  and  introduces  it,  so  that  the  bone  lies  in  the  niche  of  the 
fenestra  ovalis,1  with  benefit  to  the  hearing. 

Michael "  instills  glycerine,  in  some  cases  medicated  with 
tannin,  and  then  collodion,  and  thus  forms  a  membranous  cover- 
ing, of  which  he  speaks  highly.  Hartmanna  recommends,  in 
cases  where  the  other  varieties  of  artificial  membranse  tympani 
do  not  prove  serviceable,  a  noose  of  the  most  delicate  and  elastic 
whalebone,  wound  about  with  cotton. 

In  introducing  this  appliance  the  auditory  canal  must  be 
straightened,  by  pulling  back  the  auricle,  while  the  bone  is 
placed  in  position,  somewhat  anteriorly  in  the  depth  of  the 
canal.  Its  use  requires  some  care,  but  this  may  be  said  of  all 
artificial  membranes ;  for,  as  I  have  said,  stupid  adults  and 
children  cannot  use  them  successfully.  Polaki  uses  paper  disks 
with  great  success. 

Prognosis.  —  The  prognosis  in  chronic  suppuration  of  the 
middle  ear  depends  upon  a  variety  of  local  and  constitutional 
symptoms.  If  the  consequences  of  chronic  suppuration  have 
occurred,  such  as  exfoliation  and  death  of  bone,  the  formation 
of  polypi,  exostoses,  and  so  on,  the  treatment  is  apt  to  be  pro- 
longed, and  in  some  cases  may  never  be  entirely  or  even  partial- 
ly successful.  Again,  when  the  membrana  tympani  is  entirely 
removed,  and  one  or  more  of  the  ossicula  lost,  the  prognosis  is 
grave.  Yet  the  membrana  tympani  has  a  regenerative  power 
second  to  that  of  no  other  membrane  of  the  body.  I  have  re- 
peatedly seen  it  entirely  restored  after  all  but  a  narrow  rim 
had  been  entirely  swept  away.  This  has  even  occurred  in  cases 
of  long  standing.  The  prompt  healing  of  the  drum-head  after 
operative  perforation  and  in  acute  inflammation,  is  a  matter  of 
common  experience. 

The  state  of  the  general  system  will  also  at  times  influence 
the  prognosis  to  a  marked  degree.  Patients  with  phthisis  pul- 
monalis  seldom  recover  from  a  spontaneous  rupture  of  the  mem- 
brana tympani.  The  physician  will  find  ample  material  for 
general  advice  in  some  cases,  and  yet  there  are  many  in  which 

1  Politzer :  Text-book,  p.  492,  original  p.  563. 

*  Transactions  of  International  Congress,  London,  vol.  iii. ,  p.  434. 

*  Die  Krankheiten  des  Ohres,  p.  99. 


CHRONIC   SUPPURATION— CASES.  469 

local  treatment  only  is  required ;  while  it  is  essential  in  all.  We 
may  say,  on  the  whole,  that  the  prognosis  can  never  be  decid- 
edly given  so  long  as  the  membrana  tympani  is  open,  for  this 
membrane  is  essential  to  the  safety  of  the  ear  from  renewed 
attacks  of  acute  suppuration.  All  our  efforts  should  be  directed, 
therefore,  to  closing  up  this  opening.  There  can  be  no  danger 
from  closing  it  too  soon.  Our  chief  difficulty  will  be  in  closing 
it  at  all.  If  the  membrane  canno,t  be  restored,  the  tympanic 
tissue  may  sometimes  be  made  cicatricial,  and  thus  the  suppu- 
ration be  stopped.  If  regular  and  careful  treatment  by  a  phy- 
sician, continued  for  months,  fails  to  close  the  opening,  or  to 
cause  the  discharge  of  pus  to  cease,  the  patient  may  perhaps  be 
given  up  as  one  for  whom  there  is  no  hope  of  cure.  The  family 
and  friends  should  be  taught  to  cleanse  the  ear  thoroughly,  as 
long  as  any  purulent  inflammation  occurs,  and  they  should 
know  that  the  chief  danger  to  the  ear,  and  the  general  system, 
lies  in  an  accumulation  and  retention  of  pus. 

Patients  suffering  from  an  accumulation  and  discharge  of 
pus  from  the  tympanum  cannot  be  too  careful  of  their  general 
health.  A  simple  cold  in  the  head  may  be  fatal  to  them  by 
causing  an  inflammation  of  the  ear,  followed  by  meningitis. 
Every  year  of  my  practice  brings  to  my  attention  fatal  cases  of 
this  kind. 

CASES. 

CASE  I. — Chronic  Suppuration  of  Twelve  Years'  Standing — Exostosis  of  Tym- 
panic Cavity — Patient  under  Treatment  for  more  than  Three  Years — Both  Mem- 

brance  Tympani  Healed— Hearing  Distance  remains  the  same. — W.  P.  H ,  aged 

thirty-two.  June,  1869.  History :  Ten  or  twelve  years  ago,  from  some  cause 
to  patient  unknown,  the  right  ear  began  to  discharge,  and  then  the  left.  They 
have  discharged  at  intervals  ever  since.  Occasionally  there  is  pain  in  the 
ear. 

The  hearing  distance  is  R.,  $4  ;  L-,  -4V  The  right  membrana  tympani  is  in 
a  state  of  ulceration  ;  about  one-third  is  gone.  The  lower  and  posterior  quad- 
rant remains.  Considerable  pus  lies  in  the  cavity  of  the  tympanum.  The  left 
membrane  is  nearly  gone.  There  is  a  small  granulation  springing  from  the 
cavity  of  the  tympanum.  The  pharynx  is  tolerably  healthy. 

The  patient  was  ordered  to  use  warm  douche  daily.  He  visited  me  three 
times  a  week,  when  the  ears  were  cleansed  by  the  syringe  and  warm  water,  and 
Politzer's  method,  and  an  astringent,  usually  the  sulphate  of  zinc,  was  instilled. 
In  November,  in  about  four  months  from  the  time  of  my  first  seeing  him,  the 
left  membrana  tympani  had  healed.  The  granulation  disappeared  with  no  other 
treatment  than  the  cleansing  and  the  use  of  an  astringent. 

March  17,  1870.— The  right  membrana  tympani  now  exhibits  a  clearly  cut 
opening  in  the  posterior  and  inferior  quadrant.  A  small  amount  of  pus  oozes 
from  it.  A  minute  but  positive  elevation  of  bone  comes  out  to  the  opening. 
The  hearing  is  at  times  very  poor,  on  account  of  the  blocking  of  the  tympanic 


470  CHRONIC   SUPPURATION— CASES. 

cavity  by  pus.  The  patient  has  been  under  my  observation  ever  since  first  note, 
often  coming  to  the  office  every  day.  Nitrate  of  silver,  nitric  acid,  various  as- 
tringents, with  the  continuance  of  the  douche  and  syringe,  have  been  employed 
in  vain. 

March  17,  1871. — The  patient  has  just  passed  through  an  attack  of  acute 
catarrh,  induced  by  taking  cold.  The  hearing  distance  became  -4ug-  during  this 
attack.  Leeches  were  used,  and  subsequently  the  catheter,  steam  being  passed 
through  it.  After  the  subsidence  of  the  inflammation,  the  opening  in  the  mem- 
brana  tympani  was  found  to  be  very^much  smaller.  It  was  then  cauterized  with 
the  mitigated  stick  of  nitrate  of  silver,  melted  upon  a  probe,  and  in  a  few  weeks 
it  healed  entirely;  so  that  in  October,  1872,  he  was  dismissed,  with  H.  D., 
B.,  H ;  L.,  -/if,  and  both  drum  membranes  healed. 

I  have  not  attempted  to  give  the  full  notes  of  this  interesting 
but  tedious  case.  I  have  inserted  it  to  show  what  perseverance 
on  the  part  of  the  patient  will  finally  accomplish  in  some  cases 
of  chronic  suppuration.  There  were  no  peculiar  means  of  treat- 
ment adopted  during  the  three  years  the  patient  was  under  my 
care  ;  but  he  was  informed  that  it  might  require  years  to  heal 
the  drum-heads.  He  realized  the  danger  from  a  continued  sup- 
puration, as  well  as  the  inconvenience  and  discomfort,'  and  he 
determined  never  to  give  up  the  attempt  to  cure  it.  Very  few 
patients  will  submit  to  such  a  prolonged  observation  or  treatment 
without  faltering  in  their  allegiance  to  their  medical  adviser. 

I  have  seen  this  patient  while  preparing  tnese  pages  for  the 
press.  Two  years  ago  he  had  an  acute  inflammation  of  the  right 
ear,  which  subsided,  but  which  left  a  small  opening  without 
ulceration.  His  hearing  distance  for  the  watch  varies,  but  is 
generally  very  good  and  he  hears  conversation  well.  He  is  still 
actively  engaged  in  business  as  a  merchant,  fourteen  years 
since  he  left  my  care. 

CASE  II. — Suppuration  in  both  Tympanic  Cavities  for  Fifteen  Years,  a  ResuU 
of  the  Pharyngeal  Inflammation  of  Scarlet  Fever — No  Treatment  since  First  At- 
tack— Healing  of  one  Drum-head,  with  Great  Improvement  to  Hearing  Power — 

Other  Membrane  still  Open. — Mr.  A ,  aged  twenty-six.  November,  1870. 

Since  patient  was  eleven  years  old,  when  he  had  scarlet  fever,  he  has  had  a  dis- 
charge from  both  ears,  with  great  impairment  of  hearing.  Hearing  distance — 
right  ear,  /„- ;  left,  -4Lg.  The  membranse  tympani  on  each  side  are  removed  by 
ulceration.  There  is  a  large  amount  of  pus  in  each  canal,  with  granulations 
which  bleed  readily. 

The  ears  were  treated  by  the  warm  douche,  the  syringe,  and  Politzer's 
method  of  inflation.  The  latter  at  once  improved  the  hearing,  so  that  the  watch 
was  heard  at  4  inches,  ,48,  on  the  left  side.  Some  inflammatory  reaction  was 
caused  in  a  few  days  by  the  cleansing  process,  and  the  douche  only  could  be 
employed.  The  patient  was  seen  from  once  to  twice  a  week,  and  used  the  douche 
and  an  astringent  at  home.  One  year  after,  his  hearing  distance  was — R.,  A  > 
L.,  H.  The  left  membrana  tympani  has  just  healed. 

April  16,  1872,  or  nearly  a  year  later,  having  been  seen  at  longer  or  shorter 


CHRONIC   SUPPURATION — CASES.  471 

intervals  ever  since,  and  having  kept  up  the  treatment  at  his  home,  the  hearing 
distance  of  the  left  ear  is  !HJ.  The  patient  has  still  occasional  attacks  of  sub- 
acute  suppuration  from  right  ear.  His  hearing  power  for  conversation  is  ex- 
cellent, aud  no  true  pus  is  found  in  right  tympanic  cavity,  but  some  stringy 
mucus  is  forced  out  by  Politzer's  method. 

January,  1873. — The  patient  is  still  seen  at  long  intervals.  The  condition  of 
the  ears  remains  about  the  same. 

CASE  III. — Suppuration  of  both  Middle  Ears,  occurring  without  Pain — Half  of 
each  Membrana  Tympani  gone — Moderate  Amount  of  Pus  Secreted — Treatment  did 
not  avail  to  Improve  the  Hearing  Power — Artificial  Membrana  Tympani  used  with 

Benefit.— E.  K.  T ,  aged  twenty-eight.  November,  1872.  Three  months  since, 

patient  found,  on  awaking  in  the  morning,  that  both  ears  were  discharging. 
There  was  no  pain  experienced  in  them.  He  had  had  naso-pharyngeal  catarrh 
for  some  time,  which  had  been  treated  regularly  by  the  use  of  the  nasal  douche 
and  the  posterior  nares  syringe.  The  patient  is  not  in  very  good  general  health. 
He  has  had  a  pulmonary  hemorrhage,  and  evidently  has  phthisis  pulmoualis. 
He  hears  the  watch  six  inches  on  the  right  side,  two  inches  on -the  left.  Hear- 
ing distance — B.,  A ;  L.,  A-  The  pharynx  is  granular.  The  anterior  and  in- 
ferior quadrant  of  the  membrane  is  gone.  The  remainder  ef  the  membrane  is 
white,  and  does  not  reflect  light.  The  left  membrane  also  has  a  large  perfora- 
tion, the  anterior  half  being  absent,  and  the  remainder  of  the  membrane  looking 
like  the  right.  There  is  a  moderate  amount  of  pus  secreted  in  the  tympanic 
cavity.  The  auditory  canals  are  red  and  sensitive.  The  patient  has  already 
had  more  or  less  systematic  treatment,  and  he  cleanses  his  ears  daily  by  syring- 
ing. There  are  great  variations  in  the  hearing  power. 

The  patient  was  seen  daily  for  some  six  weeks,  and  efforts  made  to  heal  the 
membraiia  tympani  by  the  use  of  sulphate  of  zinc,  alum,  sulphate  of  copper, 
and  nitrate  of  silver,  in  solution  and  in  solid  form.  Cod-liver  oil  was  given,  and 
the  general  condition  improved,  but  the  membranae  tympani  did  not  heal  in  the 
slightest,  although  the  discharge  was  lessened,  and  the  condition  of  the  auditory 
canals  was  improved. 

February  15,  1873. — The  patient's  hearing  power  continued  to  grow  worse, 
when  the  artificial  membranse  tympani  were  inserted,  with  immediate  benefit  to- 
the  hearing  power,  so  that  he  could  transact  his  business,  which  was  that  of  a 
commercial  traveller.  Hearing  distance — R.,  A ;  L-j  A- 

April  15. — The  patient  is  still  wearing  the  membranes  with  the  same  benefit. 
The  ears  are  daily  cleansed  by  syringing,  and  an  astringent  is  dropped  upon 
them.  Mr.  T says  that  he  cannot  hear  "at  all"  without  the  artificial  mem- 
branes. 

It  has  been  a  common  observation  with  the  patients  who  use 
an  artificial  membrana  tympani,  that  they  cannot  hear  as  well 
after  removing  the  artificial  drum-heads  as  they  did  before 
wearing  them.  Yet  in  som^  cases,  the  improvement  continues 
for  hours  after  they  are  removed.  The  latter  effect  is  probably 
due  to  the  fact  that  the  restored  continuity  of  the  ossicula  and 
the  fenestra  ovalis  is  kept  up,  even  after  the  agent  that  caused 
the  restoration  is  removed. 

CASE  IV.—  Chronic  Suppuration  of  Ten  Years'  Duration  Stopped  in  Three  Days 


472  CHRONIC   SUPPURATION — CASES. 

by  the  Removal  of  a  Small  Granulation  through  the  Drum-head,  and  the  Application 

of  Nitrate  of  Silvei — Hearing  Power  Improved. — R.  R .  November  8,  1872 

(sent  to  me  by  Dr.  H.  C.  Eno).  When  the  patient  was  sixteen  years  old  he 
"  got  cold  in  the  right  ear;"  the  ear  was  very  painful;  it  discharged  and  has 
continued  to  do  so  ever  since.  It  has  been  under  careful  treatment  for  some 
months,  and  does  not  discharge  as  much  as  it  did.  The  hearing  distance  is  ^. 

On  examination,  a  slight  amount  of  pus  is  found  upon  the  membrana  tym- 
pani.  On  removing  this,  a  small  granulation  is  seen  perforating  the  membrane 
in  the  anterior  and  inferior  quadrant. 

November  9. — The  granulation  was  removed  by  means  of  a  pair  of  angular 
forceps.  A  solution  of  nitrate  of  silver,  gr.  xl.  ad  3  j.,  was  applied  in  the  open- 
ing, after  a  thorough  cleansing  of  the  ear  by  syringing  and  Politzer's  method. 

November  10. — The  opening  of  the  membrane  has  closed.  The  patient 
remained  under  observation  until  November  22d,  and  suppuration  did  not  again 
occur.  The  hearing  distance  became  -A. 

1870. — This  membrane  continues  sound,  although  the  patient  has  had  eczema 
of  the  canal  and  perforation  in  another  part  of  the  membrane  once,  since  the  one 
here  described  healed. 

It  may  be  thought  that  these  cases  illustrate  the  bright  side 
of  the  treatment  of  chronic  suppuration  ;  but  I  do  not  think  they 
are  any  more  than  average  specimens  of  cases  of  simple  ulcera- 
tion,  that  is,  ulcerations  unattended  by  death  of  bone.  When 
caries  or  necrosis  of  any  part  of  the  walls  of  the  cavity  has 
occurred,  the  prognosis  is  very  unfavorable  for  a  perfect  arrest 
of  the  morbid  process.  I  have  not  found  so  much  difficulty  in 
relieving  uncomplicated  cases  of  chronic  suppuration,  as  in  find- 
ing patients  who  were  patient  enough  to  submit  to  the  tedious 
treatment  necessary  to  a  cure.  Distrust  of  the  advice  of  the 
profession  is  nowhere  more  common  than  in  cases  of  chronic 
suppuration,  in  regard  to  which  the  laity  have  been  taught  two 
erroneous  and  contradictory  doctrines,  first,  that  a  discharge 
from  the  ear  is  seldom  checked  ;  second,  that  it  is  dangerous  to 
arrest  it,  if  we  can. 


CHAPTER  XVII. 

THE  CONSEQUENCES  OF  CHRONIC  SUPPURATION  OF  THE 
MIDDLE  EAR. 

Chronic  Suppuration  and  its  Results  Inevitably  Dangerous  to  the  Health  and  Life  of 
the  Patient. — Refusal  of  Life  Insurance  Companies  to  take  Risks  of  such  Cases. — 
Cicatrices  and  Adhesions  in  the  Tympanum. — Polypi. — Exostoses. — Mathewson's 
Operation  for  their  Removal. — Cases. 

IF  a  chronic  suppurative  process  in  the  middle  ear,  remained  a 
simple  ulcer,  with  none  of  the  consequences  that  are  very  liable 
to  result  from  it,  it  would,  perhaps  be  a  condition  of  things  to  be 
preferred  to  a  chronic  proliferous  process  in  the  same  part.  For 
in  simple  chronic  ulceration,  the  hearing  power  is  often  very 
good,  the  tinnitus  aurium  is  not  usually  excessive,  and  some- 
times does  not  exist,  and  it  may  generally  be  relieved  by  simple 
syringing  and  inflation  of  the  ear.  These  are  the  symptoms 
which  are  so  trying,  in  the  non-suppurative  form  of  disease, 
that  people  have  become  insane  on  account  of  them.  But  the 
almost  inevitable  consequences  of  chronic  suppuration  in  the 
middle  ear,  are  dangerous  to  the  health  and  life  of  the  patient. 
Hence  the  importance  of  the  subject,  and  the  interest  which 
every  physician  should  take  in  arresting  the  advance  of  this 
disease. 

It  is  in  view  of  these  consequences,  that  English  life  insur- 
ance companies  are  said  to  decline  to  insure  the  lives  of  persons 
that  are  affected  with  chronic  suppuration  of  the  middle  ear. 
A  little  consideration  will  show  that  any  person  who  has  a  hole 
in  the  membrana  tympani,  and  an  ulcerative  process  in  the 
parts  beyond,  has  a  much  less  chance  for  long  life  than  one 
whose  brain  and  vascular  circulation  are  not  thus  exposed  t& 
the  ravages  of  disease..  Very  few  persons,  comparatively,  who 
suffer  from  chronic  suppuration,  live  out  their  days,  while  many 
of  them  die  very  young. 

Among  the  possible  and  not  infrequent  consequences  of 
chronic  suppuration  of  the  middle  ear  are — 

1.  Cicatrices  and  adhesions  in  the  drum-head  and  tympanum. 

2.  Polypi. 


474  CONSEQUENCES   OF   CHRONIC   SUPPURATION. 

3.  Exostoses. 

4.  Mastoid  disease. 

5.  Caries  and  necrosis  of  the  temporal  bone. 

6.  Cerebral  abscess. 

7.  Pyaemia. 

8.  Paralysis. 

CICATRICES  AND  ADHESIONS. 

In  some  fortunate  cases  of  chronic  suppuration,  as  we  have 
seen,  an  end  is  finally  reached  by  a  closure  of  the  membrana 
tympani.  This  may  even  occur  when  one  or  all  of  the  ossicles 
have  been  removed.  The  impairment  of  hearing  may  be  very 
great,  with  a  neoplastic  membrana  tympani,  but  the  danger  to 
life  and  to  the  general  health,  is  much  lessened  by  a  closure  of 
the  tympanum.  Healing  of  the  ulcerated  membrana  tympani,  is 
therefore  a  result  to  be  desired,  even  if  the  hearing  be  not  as 
great  after  this  has  occurred,  as  it  was  when  it  was  perforate 
and  ulcerating.  The  drum-head,  however,  may  not  close,  and 
yet  its  edges  cicatrize  and  adhere  to  the  tympanic  wall.  The 
tympanum  then  will  be  converted  into  a  dry  chamber,  its  mu- 
cous membrane  so  altered  that  it  scarcely  secretes,  and  only 
under  great  provocation  takes  on  inflammatory  action.  It  is 
sometimes  difficult  in  such  cases  to  determine  what  is  left  of  the 
normal  furniture  of  the  tympanum,  such  a  mass  is  it,  of  displaced 
and  neoplastic  tissue.  If  the  stapes  bone  still  remain,  or  even  its 
foot-plate,  it  is  sometimes  possible  to  use  an  artificial  membrana 
tympani  with  great  benefit ;  but  generally  the  adhesions  and 
cicatrices  involve  so  much  of  the  air  chamber,  with  perhaps  an 
extension  into  the  tissues  of  the  labyrinth,  that  literally  nothing 
can  be  done  for  the  patient,  except  to  leave  his  ears  to  them- 
selves. Bad  as  this  condition  is,  it  is  a  more  favorable  one  than 
when  the  ulcerative  process  still  continues,  with  perhaps  some 
one  or  more  of  the  results  that  are  now  to  be  described. 

POLYPI. 

Celsus  and  Pliny,  used  the  term  polypus  for  a  tumor  springing 
from  any  cavity  of  the  body.  The  name  was  adopted  under  the 
old  system  of  nomenclature,  when  an  exact  knowledge  of  the 
nature  and  structure  of  growths  or  parts  was  not  regarded  in 
giving  them  a  name.  It  is  an  unfortunate  one,  for  there  is 
scarcely  any  resemblance  between  the  many -footed  aquatic 
animal,  after  which  morbid  growths  were  called,  and  the  exub- 
erant granulations  or  tumors  which  arise  from  the  cavity  of  the 


POLYPI.  475 

tympanum  and  the  auditory  canal.  It  is  probably  too  late,  or 
too  early,  to  effect  any  change  in  the  nomenclature,  and  we 
must  be  content  with  the  name  aural  polypi  for  all  the  growths 
that  occur  in  the  ear,  except  for  those  of  an  osseous  structure  or 
a  cancerous  nature. 

The  best  classification  of  aural  polypi,  seems  to  me  to  be  that 
of  Steudener, '  who  divides  them  into  three  varieties  : 

1.  Mucous  polypi. 

2.  Fibromata. 

3.  Myxomata. 

To  this  we  may  add  a  fourth  class : 

4.  Angioma ;  a  case  of  which,  as  occurring  in  the  ear,  was 
first  reported  by  Dr.  A.  H.  Buck.2 

Cases  of  epithelioma,  sarcoma,  and  cholesteatoma  have  also 
been  reported,  but  they  do  not  properly  belong  to  the  subject  of 
aural  polypi,  although  they  are  sometimes  confounded  with  the 
simple  growths,  and  perhaps  arise  from  them.  For  the  sake  of 
convenience,  their  consideration  will  be  deferred  until  the  be- 
nignant tumors  have  been  considered.  Kessel*  also  reports  a 
peculiar  growth,  which  is  called  a  clot  of  blood  in  process  of 
organization,  but  it  hardly  requires  a  separate  classification. 

The  mucous  polypi  are  altogether  the  most  frequent  of  those 
found  in  the  ear.  The  fibromata,  or  polypi,  made  up  of  denser 
connective  tissue  than  the  mucous  growths,  are  next  in  fre- 
quency. Buck,  thinks  that  about  one  in  ten.  of  all  the  polypi 
that  have  been  microscopically  examined,  belong  to  the  class  of 
fibroma.  Myxoma,  has  been  reported  by  Steudener  only,  so  far 
as  I  have  been  able  to  find. 

Nature  of  Aural  Polypi. — In  an  article  published  in  1864,4  I 
attempted  to  show  on  clinical  grounds,  that  aural  polypi  were 
analogous  in  structure  to  exuberant  granulations,  occurring  as 
direct  results  of  an  ulcerative  process.  This  view  at  once  clears 
up  the  nature  of  these  growths  and  takes  away  the  fictitious 
importance  which  the  view  that  regards  them  as  independent 
tumors  caused  them  to  assume.  Professor  Theodore  Billroth, 
in  1855,  whose  monograph  I  had  not  then  seen,  examined  seven 
polypi  which  were  found  in  the  external  auditory  canal,  and 
Kessel "  quotes  him  as  stating  that  the  chief  contents  of  those 
polypi  were  granulation  material,  although  he  states  that  the 

1  Archiv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  203. 

2  Transactions  of  the  American  Otological  Society,  1870. 

3  Archiv  fiir  Ohrenheilkunde,  Bd.  IV.,  p.  187. 

4  American  Medical  Times,  August  C,  1864. 

5  Archiv  fiir  Ohrenheilkunde,  loc.  cit. 


476 


POLYPI. 


existence  of  ciliated  epithelium  and  the  vascular  network  en- 
titles them  to  the  rank  of  independent  tumors.  Bill  roth's  idea 
as  to  the  nature  of  mucous  polypi  is  perhaps  the  most  correct 
and  the  simplest.  They  consist  of  a  delicate  but  loose  stroma 
of  connective  tissue.  In  the  meshes  of  this  connective  tissue 
are  round,  spindle-shaped,  or  stellate  cells,  and  they  are  covered 
by  a  single  or  multiple  layer  of  epithelium  cells. 

The  fibrous  polypi  consist  of  a  dense  connective  tissue,  hav- 
ing but  few  cellular  elements  in  its  fibres  and  covered  by  pave- 
ment epithelium. 


FIG.  101. — Section  of  Aural  Polypus,  Case  T.  A,  Layer  of  laminated  epithelium,  similar  to 
that  of  skin ;  £,  B,  epithelial  cones,  the  commencement  of  gland  formation ;  C,  loose  con- 
nective tissue,  containing  round  and  spindle  cells  and  some  fibres  ;  D,  blood-vessels. 

Angioma  is  made  up  of  newly  formed  vessels,  or  of  vessels 
in  whose  walls  are  newly  formed  elements.  It  is  quite  a  com- 
mon variety  of  tumor,  although  the  case  to  which  allusion  has 
already  been  made,  is  the  only  one  that  has  been  reported  as 
having  been  found  in  the  ear.  Virchow '  named  the  form  which 
Dr.  Buck  examined,  angioma  cavernosum,  because  it  was  char- 
acterized by  the  existence  of  a  network  of  blood  spaces,  occupy- 
ing the  place  and  doing  the  work  of  capillary  vessels. 

It  may  be  said  in  general  terms,  however,  that  aural  polypi 
are  growths  covered  by  laminated  epithelium,  and  that  they 
consist  of  loose  connective  tissue,  containing  round  and  fusi- 
form cells  and  a  proportionately  large  number  of  blood-vessels. 
Their  internal  structure  in  some  cases  gives  evidence  of  the  for- 
mation of  glands. 

Dr.  H.  C.  Eno,  formerly  Pathologist  to  the  Manhattan  Eye 

1  Die  krankhaften  Geschwiilste,  IIL  Bd.,  Hf.  I.,  p.  307. 


POLYPI. 


477 


and  Ear  Hospital,  and  Surgeon  to  the  New  York  Eye  and  Ear 
Infirmary,  examined  three  specimens  of  aural  polypi,  which  I 
removed  from  the  auditory  canal,  and  made  drawings  of  their 
structure.  These  drawings  will,  I  think,  better  illustrate  the 
nature  of  these  growths  than  further  remarks. 

CASE  I. — Thomas  G ,  aged  twenty-three.  March  14,  1871.  Brooklyn 

Eye  and  Ear  Hospital. 

History. — Seven  days  ago  extensive  swelling  in  meauricular  region ;  granu- 
lations springing  out  of  auditory  canal. 

Diagnosis. — Abscess  of  anterior  wall  of  auditory  canal,  with  polypoid  growth 
arising  from  same  point. 

Treatment. — Polypus  removed  and  abscess  opened  ;  ordered  chloral  hydrate, 
gr.  xv. ;  if  does  not  sleep  well  to-night,  to  come  at  12  M. 

March  16th. — Continue  treatment. 

March  18th. — Touched  polypus  with  nitric  acid. 

March  21st.  — Much  better  ;  touched  with  argent  nit.  mit. 

It  should  be  said  that  the  usual  point  of  origin  of  aural  pol- 
ypi, is  the  cavity  of  the  tympanum.  They  may  arise  from  the 
auditory  canal,  but  if  so,  they  are  the  result  of  suppuration,  that 
has  been  prolonged,  or  that  has  been  augmented  by  the  use  of 


J 


FlG.  102.— Section  of  Aural  Polypus,  Case  II.  A,  Epithelium  ;  B,  substance  of  polypus, 
made  up  of  a  mass  of  round  cells  about  the  size  of  white  blood-corpuscles  ;  O,  C,  capillary 
vessels,  containing  white  blood-corpuscles. 

poultices,  and  which  have  rapidly  broken  down  the  integument 
of  the  canal,  and  rendered  it  more  like  its  neighbor,  the  mucous 
membrane  of  the  tympanic  cavity.  Polypi  and  granulations 
often,  however,  have  their  seat  in  the  canal,  but  they  are  usu- 
ally accompanied  by  the  same  growth  in  the  deeper  parts,  when 
the  whole  character  of  the  tissue  lining  the  canal  has  been 


478 


POLYPI. 


changed  by  an  ulcerative  process,  extending  from  the  tympanic 
cavity.  As  will  be  seen  by  comparing  the  illustrations  of  Case 
I. ,  which  arose  from  the  auditory  canal,  with  those  that  sprang 
from  the  cavity  of  the  tympanum,  the  only  essential  difference 
is  that  the  epithelium  is  thicker. 

CASE  n. — Mary  Jane  N ,  aged  thirteen.    January  10,  1872.     Manhattan 

Eye  and  Ear  Hospital.  Otitis  media  suppurativa,  with  polypus  in  right  ear. 
Polypus  nearly  fills  auditory  canal.  Discharge  from  both  ears  from  scarlet 
fever  since  a  child.  Large  perforations  in  membranes  tympani.  Polypus  re- 
moved with  snare. 


FIG.  103.— Section  of  Aural  Polypi.  A,  f,  and  D,  same  as  in  Fig.  101 ;  E,  gland  lined  with 
cylindrical  epithelium  ;  f,  transverse  section  of  the  same. 

CASE  HE. — Mary  Ann  McC ,  aged  fourteen.  January  24,  1871.  Man- 
hattan Eye  and  Ear  Hospital. 

History.  — Discharge  from  right  ear  since  a  child.     Cause  unknown. 

Diagnosis. — Otitis  media  suppurativa,  with  polypus  of  right  ear. 

Hearing. — B.,  watch  heard  on  contact.     L.,  normal. 

Meatus. — E.,  full  of  pus. 

Treatment. — Syringed.  January  31st. — Two  polypi  removed  with  snare. 
Douche  and  syringing.  Politzer,  warm  douche.  Nitric  acid  to  stumps.  Hear- 
ing distance  increased  to  2". 

Aural  polypi  are  more  rarely  found  by  the  physicians  of  to- 
day than  by  our  predecessors,  for  the  simple  reason  that  aural 
diseases  are  more  carefully  observed,  and  they  have  no  such 
opportunities  to  occur,  as  were  enjoyed  when  a  discharge  of 
pus  from  the  ear  was  not  treated.  A  tumor  can  scarcely  arise 
from  a  tympanic  cavity  or  an  auditory  canal  that  is  kept  thor- 
oughly free  from  the  pus  of  a  chronic  suppurative  process. 


MALIGNANT  GROWTHS.  479 


MALIGNANT  GROWTHS. 

The  malignant  growths  that  have  as  yet  been  found  in  the 
ear,  and  which  may  be  mistaken  for  malignant  polypi,  are  epi- 
thelial carcinoma,  fibrous  and  medullary  carcinoma.  Gruber ' 
relates  a  case  where  an  epithelial  carcinoma  originated  in  the 
integument  in  the  region  of  the  mastoid  bone,  gradually  de- 
stroyed the  mastoid  process,  and  finally  reached  the  mucous 
membrane  of  the  middle  ear.  The  membrana  tympani  was  de- 
stroyed by  the  growth.  The  patient  heard  a  watch  when  laid 
upon  this  ear  ;  he  had  no  tinnitus  aurium,  and  so  few  symp- 
toms beyond  extremely  slight  lancinating  pain,  that  after  the 
tumor  had  existed  for  three  years,  he  still  did  his  work  as  a  day 
laborer. 

Dr.  Robertson,"  reports  a  case  of  supposed  polypus  in  the 
ear,  which  proved  to  be,  on  microscopic  examination,  a  specimen 
of  "  fasciculated  sarcoma  corresponding  to  plates  of  tumors  con- 
stituted by  embryonic  tissue,  found  in  the  '  Manual  d'Histologie 
Pathologique,'  by  Cornil  and  Ranvier  of  Paris."  An  attempt  to 
remove  the  growth  by  cutting  off  pieces  of  it  caused  a  hemor- 
rhage of  fourteen  fluid  ounces  in  a  few  moments.  The  hemor- 
rhage was  arrested  by  a  tampon  of  cotton  dipped  in  a  solution 
of  persulphate  of  iron. 

Cholesteatoma,  the  pearl  tumors  of  J.  Miiller,  have  also  been 
found  in  the  cavity  of  the  tympanum,  arising  from  an  inflamed 
or  ulcerated  mucous  membrane.  They  consist,  according  to 
Gruber,3  of  small  degenerated  epithelial  cells,  between  which 
lie  cholestearine  crystals  and  other  fatty  material.  They  some- 
times destroy  the  bone  by  pressure,  and  they  may  even  extend 
into  the  cranial  cavity. 

Osteo-sarcoma  of  the  cavity  of  the  tympanum,  extending 
into  the  auditory  canal,  was  also  observed  by  Boke.4  The  pa- 
tient died  of  meningitis.  Wilde 6  reports  an  interesting  case  of 
osteo-sarcoma.  A  boy  of  seven  years  of  age.  in  apparently  good 
health,  was  brought  to  Mr.  Wilde  on  account  of  a  discharge 
from  the  external  auditory  canal.  A  small  polypus  was  dis- 
covered. It  was  removed,  but  it  returned  quickly  on  the  third 
day.  It  was  again  and  repeatedly  removed,  but  it  recurred 
again  and  again,  and  subsequently  the  child  was  seized  with  an 
epileptic  fit.  A  fluctuating  point  was  then  found  upon  the  mas- 
toid process  ;  this  was  cut  down  upon  at  once,  and  the  opening 
gave  exit  to  a  large  amount  of  pus.  The  abscess  communicated 

1  Text-book,  p.  597.  *  Transactions  of  the  American  Otological  Society,  1870. 

3  Lehrbuch,  p.  597.  4  Gruber,  loc.  cit.  5  Text-book,  p.  280. 


480  TREATMENT   OF   POLYPI. 

by  a  fistula  with  the  external  auditory  canal.  A  fungous 
growth  soon  sprouted  up  through  the  incision.  Repeated  at- 
tacks of  epilepsy  occurred,  and  death  soon  ensued.  Upon  ex- 
amination there  was  found  an  osteo-sarcoma  of  the  petrous 
and  mastoid  portions  of  the  temporal  bone.  Wilde  thinks  that 
the  original  disease  was  in  the  bone,  and  that  the  aural  dis- 
charge and  fungus  were  but  secondary  appearances.  The  his- 
tory is  not  detailed  enough  to  allow  us  to  state  with  any  posi- 
tiveness  the  first  cause  of  the  affection,  but  it  may  have  been 
an  ulcer  in  the  tympanic  cavity,  which  secondarily  involved 
the  bone. 

These  malignant  tumors  of  the  ear  should  be  carefully  dis- 
tinguished from  the  benign  mucous  and  fibrous  polypi  that  are 
the  frequent  results  of  a  neglected  suppuration.  Yet  it  should 
be  remembered  that  the  malignant  growths  may  be  also  the 
result  of  the  same  original  process.  This  fact  adds  to  the  im- 
portance of  the  subject.  Perhaps  some  of  the  cases  of  death 
from  the  removal  of  aural  polypi  should  be  referred  to  the  ex- 
tension of  the  malignant  disease,  rather  than  to  the  excision  of 
a  tumor  from  the  ear. 

Treatment. — The  treatment  of  an  aural  polypus  should  be- 
gin with  the  removal  of  the  growth.  I  have  said  begin  with 
deliberation,  because  it  is  a  mistake  to  suppose  that  the  removal 
of  the  polypus  will  be  any  more  than  the  beginning  of  the 
treatment  of  the  disease  of  which  the  polypus  is  a  symptom. 
Besides,  aural  polypi  often  spring  up  very  rapidly,  even  after 
they  have  been  thoroughly  removed,  and  when  they  are  simple 
growths ;  moreover,  we  are  often  obliged  to  remove  them  sev- 
eral times  from  the  ear,  especially  where  we  cannot  have  full 
control  of  our  patients  and  cause  them  to  attend  to  the  after- 
treatment. 

Wilde's  snare,  as  modified  by  Blake  (Fig.  104),  will  be  found 
the  best  instrument  for  the  removal  of  well-defined  polypi  with  a 
pedicle.  In  Wilde's  snare,  the  bar  which  carries  the  slide,  and 
the  arm  which  supports  the  wire  used  in  cutting  off  the  polypus, 
are  in  one  piece.  Dr.  Blake  has  substituted  a  movable  tube  of 
German  silver  (d)  for  the  fixed  arm.  "This  tube  expands  at 
the  outer  ends  into  a  flattened  head  (/),  having  two  openings 
for  the  passage  of  the  wire ;  the  inner  end  of  the  tube  fits  into 
a  broad  band  on  the  slide-bar  (&).  The  ends  of  the  wire  passing 
down  the  tube  are  fastened  to  a  pin  on  the  upper  part  of  the 
slide  (c),  below  which  is  a  ring,  by  which  traction  can  be  made." 
The  instrument  is  better  than  Wilde's,  because  it  can  be  turned 
in  any  direction  without  injuring  the  walls  of  the  canal.  A 


POLYPI — TREATMENT. 


481 

it 


paracentesis  needle  may  also  be  used  in  the  handle,  but 
should  be  rather  longer  than  the  one  in  the  cut. 

Scissors  may  sometimes  be  used  with  advantage  to  remove 
aural  polypi.  I  have  found  those  that  are  here  represented  very 
convenient,  especially  for  the  removal  of  growths  from  the 
walls  of  the  auditory  canal. 


FIG.  104. — Blake's  Modification  of  Wilde's  Snare,  with  Paracentesis  Needle. 

Forceps  may  sometimes  be  employed,  although  I  prefer  the 
snare,  scissors,  and  curette  to  all  other  mechanical  means  for  re- 
moving polypi  or  granulations.  Forceps,  unless  used  with  great 
gentleness  and  care,  may  wrench  more  than  the  morbid  growth 
from  the  cavity  of  the  tympanum,  and  thus  do  great  harm. 

Very  small  pedunculated  growths  may  be  often  removed  by 
the  simple  angular-toothed  forceps,  figured  on  page  59  of  this 
work.  True  exuberant  granulations,  having  no  pedicle,  but 
arising  from  a  broad  surface,  usually  resist  treatment  with 
great  obstinacy,  because  they  are  difficult  to  reach  and  entirely 


FIG.  105. — Scissors  for  the  Removal  of  Aural  Polypi. 

remove  with  instruments,  and  because  they  usually  qover  cari- 
ous or  necrosed  bone.  Caustics  are  perhaps  the  only  means  of 
removing  such  growths.  The  agents  I  usually  employ  for  such 
cases  are  strong  solutions  of  nitrate  of  silver — from  forty  to  four 
hundred  and  eighty  grains  to  the  ounce — and  fuming  nitric 
acid.  The  nitrate  of  silver  may  be  poured  in  upon  the  part, 
and  then  neutralized  by  the  subsequent  instillation  of  a  solution 
of  common  salt. 

Dr.  O.  D.  Pomeroy '  reports  a  case  of  "  the  removal  of  a  poly- 


1  Medical  Record,  vol.  vi. 
31 


Reported  by  D.  Webster,  M.D. 


482 


POLYPI— TREATMENT. 


poid  granulation  of  ten  years'  standing,  by  four  applications  of 
a  forty-grain  solution  of  nitrate  of  silver."    A  pipette  was  used 
to  drop  the  nitrate  of  silver  upon  the  growth.     Although  it  is 
evident  from  the  history  that  the  dis- 
-ease  which  allowed  the  formation  of  the  Q 
polypus  —  a  chronic  suppuration    from 
scarlet  fever— had  existed  for  ten  years, 
it  does  not  certainly   appear  that  the 
polypus  had  been  in  the  ear  so  long. 
The  polypus  is  said  to  have  sprung  from 
the  membrana  tympani,  which  was  per- 
forate, however. 

I  am  in  the  habit  of  treating  granu- 
lations that  arise  from  the  cavity  of  the 
tympanum,  where  it  is  somewhat  dan- 
gerous to  use  forceps,  scissors,  or  snare, 
by  numerous  punctures  with  a  cataract 
needle.  The  puncturing  causes  consid- 
erable hemorrhage.  After  the  blood  is 
wiped  away  a  caustic  should  be  applied. 
Nitric  or  chromic  acid  may  be  thus  used, 
by  means  of  a  glass  rod,  a  cotton-holder 
armed  with  cotton,  or  a  bit  of  wood. 

The  pain  from  these  applications  is 
usually  so  little  that  even  children  will 
bear  them  without  shrinking.  The 
granulations  are  of  such  a  low  grade  of 
organization  that  they  have  very  little 
sensitiveness.  There  are,  of  course, 
many  other  agents  than  those  that  have 
been  mentioned,  which  may  be  profit- 
ably used  in  cauterizing  the  bases  of 
polypi  that  have  been  removed  by  in- 
struments, and  in  destroying  fungous 
granulations.  Chromic  acid  is  very 
much  employed,  as  well  as  the  acid  ni- 
trate of  mercury. 

Dr.  Edward  H.  Clarke  often  injects 
a  solution  of  the  perchloride  or  persul- 
phate of  iron  into  the  interior  of  a  poly-  FlG  io6._  Buck's  Curettes, 

PUS.  and  With  the  happiest  results.1    TWO    for  clearing  auditory  canal  and 
;,  ,  ,    ,, ii-  f  tympanum. 

or  three  drops  of  the  liquor  fern   per- 

chloridi,  of  the  liquor  ferri  persulphatis,  are  injected  into  the 

growth  by  means  of  a  hypodermic  syringe. 

1  On  Polypus  of  the  Ear,  p.  61. 


POLYPI— TREATMENT.  483 

Dr.  Hackley  drops  a  few  drops  of  the  persulphate  of  iron  upon 
small  granulations,  and  he  informs  me,  that  after  years  of  ex- 
perience with  this  remedy,  he  is  well  satisfied  with  the  results 
of  its  use.  I  have  lately  used  it  and  I  think  it  shrivels  the 
smaller  growths  very  well.  But  I  now  chiefly  use  the  curette 
for  small  growths. 

The  galvano-cautery  is  said  to  be  an  efficient  and  painless 
method  of  removing  granulations  from  the  cavity  of  the  tym- 
panum. Dr.  Blake  does  not  consider  it  a  painless  method  of 
perforating  the  drum-head  however,  he  having  witnessed  its 
operation,  in  Vienna,  in  some  experiments  made  by  Politzer, 
Chemani,  and  Moos.  Allusion  has  already  been  made  to  this 
means  of  puncturing  the  membrana  tympani.  In  each  of  the 
cases  observed  by  Blake,  where  an  attempt  was  made  to  per- 
forate the  membrana  tympani  with  a  galvano-cautery,  the  pain 
was  so  severe  that  further  attempts  were  abandoned.  It  is  prob- 
able, however,  that  it  is  not  so  painful  a  process  when  used  to 
remove  granulations.  Schwartze1  speaks  very  highly  of  the 
galvano-cautery  for  the  purpose  of  removing  morbid  growths. 
Although  the  pain  is  considerable,  much  more  severe  than  from 
tthe  use  of  the  pure  nitrate  of  silver,  the  reaction  is  slight. 
Schwartze  also  believes  that  the  galvano-cautery  is  a  more  effi- 
cient means  of  removing  the  growth  than  the  ordinary  caustics. 

No  difficulty  will  usually  be  found  in  the  removal  of  large  or 
pedunculated  polypi  or  granulations.  It  is  only  by  those  that 
are  small  and  flat,  arising  from  dead  bone,  and  which  are  very 
rapidly  reproduced,  that  difficulty  will  be  found.  Each  surgeon 
will  soon  learn  how  he  can  best  deal  with  the  former  variety, 
whether  with  forceps,  snare,  or  curettes.  The  latter  form,  espe- 
cially if  buried,  so  to  speak,  in  the  tympanic  cavity,  will  often 
tax  the  surgeon's  skill  and  ingenuity  to  the  utmost.  The  use  of 
alum  will  sometimes  shrivel  the  granulations  so  as  to  cause  a 
pedicle  to  show  itself.  lodoform,  as  has  been  said,  is  a  good  ap- 
plication to  pale  growths.  Alcohol  is  also  valuable.  It  should 
be  used  at  least  three  times  a  day,  and  warmed  before  it  is 
dropped  into  the  ear,  when  used  for  polypi.  It  causes  consider- 
able pain,  but  it  is  only  of  short  duration.  It  is  well  to  begin 
with  a  fifty  per  cent,  solution. 

Free  incisions  into  the  granulations,  down  to  the  bone,  by 
means  of  a  narrow  Graefe's  cataract  knife,  are  also  effective, 
especially  in  recent  cases. 

No  matter  which  of  the  methods  that  have  been  detailed,  be 
employed  in  removing  an  aural  polypus,  the  subsequent  treat- 
ment will  be  the  same.  The  case,  after  the  removal  of  the: 

1  ArcMv  fur  Ohrenheilkunde,  Bd.  IV.,  p.  8. 


484  CASE  OF  POLYPUS. 

growth — if  caries,  necrosis,  or  exostosis  do  not  exist — is  one  of 
simple  chronic  suppuration,  that  should  be  managed  in  the  man- 
ner that  has  been  set  forth  in  the  preceding  chapter.  The  re- 
moval of  the  polypus  may  improve  the  hearing  very  much,  or  it 
may  scarcely  benefit  it.  If  the  polypus  were  a  mere  mechanical 
obstruction  to  the  entrance  of  sound,  its  removal  would  of  course 
at  once  restore  the  hearing  power;  but,  as  has  been  seen,  it  is 
much  more  than  that.  The  prognosis  in  regard  to  the  hearing 
power  in  cases  of  aural  polypi  should  always  be  guarded.  The 
hemorrhage  from  their  removal  is  usually  trifling.  If  it  be 
excessive,  as  in  Dr.  Robertson's  case  of  carcinoma,  a  tampon 
saturated  in  sulphate  of  iron  will  arrest  it.  I  usually  employ 
Rohland's  styptic  cotton  for  the  arrest  of  hemorrhage  from  the 
base  of  a  polypus,  if  the  use  of  cotton-wool  do  not  check  it  at 
once.  Hot  water  is  also  a  good  styptic. 

Blake's  Middle  Ear  Mirror. 

Dr.  Blake  has  invented  a  middle  ear  mirror,  for  the  purpose 
of  examining  cases  of  suppurative  inflammation  of  the  middle 
ear  more  accurately  than  can  be  done  with  the  aural  speculum.1 
It  is  said  to  be  especially  useful  in  detecting  the  exact  site  of 
small  granulations.  The  use  of  Dr.  Blake's  instrument,  as  he 
himself  states,  "  is  of  necessity  limited  to  a  very  small  number 
of  cases,  as  both  a  moderately  wide  meatus  and  a  comparatively 
large  opening  in  the  membrana  tympani  must  exist,  to  permit 
of  the  introduction  of  a  mirror  of  sufficient  size."  The  instru- 
ment was  first  constructed  to  accurately  determine  the  origin  of 
a  growth  which  was  external  to  the  membrana  tympani,  but 
which  was  hidden  from  view  by  the  conformation  of  the  external 
auditory  canal. 

The  mirror  is  attached  to  Weber's  tenotome,  the  cutting-hook 
being  replaced  by  a  polished  steel  mirror  of  from  one-sixteenth 
to  one-eighth  of  an  inch  in  diameter.  In  some  cases  Dr.  Blake 
thinks  a  larger  mirror  may  be  used.  "The  mirror  is  made  by 
flattening  out  the  end  of  the  shaft,  bending  it  at  the  proper 
angle,  tempering  and  polishing  it.  The  shaft  is  ductile,  so  that 
the  angle  of  the  mirror  can  be  varied  at  will.  Shafts  of  various 
lengths,  with  mirrors  of  various  sizes,  may  be  used  in  the  same 
handle,  and  the  mirror  may  be  rotated  by  movement  of  the  stud 
in  the  handle." 

Polypus  in  the  Auditory  Canal  for  Forty -one  Years — Removal. — The  most 
remarkable  case  of  polypus  in  the  ear,  that  I  ever  saw,  was  one  that  came  to  me 

1  Transactions  of  the  American  Otological  Society,  1872,  p.  83. 


BONY   GROWTHS.  485 

in  1875.  The  subject  of  the  disease  was  fifty-six  years  old.  He  stated  that  he 
had  had  a  discharge  from  his  ear  ever  since  he  was  a  small  boy,  and  that  he  was 
positive  that  he  had  had  a  polypus  in  the  ear  for  forty-one  years.  The  right 
auditory  canal  was  found  to  be  filled  with  a  polypus,  and  there  was  a  slight 
amount  of  pus  in  the  canal.  The  patient  stated  that  he  had  taken  great  care  of 
his  ear  and  his  polypus  during  all  these  years.  He  brought  with  him  a  peculiar 
kind  of  cotton,  which  he  had  used  to  cleanse  the  canal  and  to  plug  the  rneatus. 
After  I  gave  him  the  advice  to  allow  the  removal  of  the  growth,  he  accepted  it, 
but  with  many  misgivings  and  great  reluctance.  He  seemed  to  believe  that  the 
most  serious  consequences  would  follow  the  removal  of  the  growth.  It  was  ef- 
fected very  easily  by  a  snare.  It  was  attached  by  a  pedicle  to  the  upper  and 
posterior  wall  of  the  canal.  The  membrana  tympani  was  whole,  but  cicatricial. 
The  hearing  power  was  nil.  The  growth  did  not  recur,  and  the  patient  has 
suffered  no  evil  consequences  from  its  removal.  I  have  no  doubt,  after  careful 
investigation,  that  this  gentleman's  account  of  the  number  of  years  the  polypus 
had  been  in  his  ear,  was  strictly  correct.  As  Dr.  Ely  remarked,  when  we  were 
advising  the  patient  to  allow  the  tumor  to  be  removed:  "It  was  a  case  of  a 
man  attached  to  a  polypus." 

For  the  benefit  of  the  student  and  young  practitioner,  we 
may  formulate  our  knowledge  of  aural  polypi  as  follows  : 

I.  True  aural  polypi  are  morbid  growths  analogous  to  ex- 
uberant granulations. 

II.  They  are  the  result  of  a  long-continued,  or  recent  and 
violent  purulent  inflammation  of  the  cavity  of  the  tympanum 
or  external  auditory  canal — usually  of  the  former. 

III.  Their  removal  is  usually  but  the  beginning,  of  a  treat- 
ment of  the  disease  of  which  they  are  consequences  and  symp- 
toms. 

IV.  The  hearing  power  of  the  patient  will  not  be  restored, 
although  usually  improved  by  the  removal  of  an  aural  polypus. 

V.  Malignant  growths  occur  in  the  ear,  which  assume  the 
form  of,  and  may  be  mistaken  for,  simple  polypi. 


BONY  GROWTHS. 

Exostoses,  hyperostoses,  or  bony  growths  sometimes  occur 
in  the  osseous  portion  of  the  auditory  canal  and  in  the  cavity  of 
the  tympanum.  They  may  be  divided  into  two  great  classes— 
the  congenital  and  acquired  forms.  With  the  congenital  we 
have  very  little  to  do.  Inasmuch  as  they  are  not  consequences 
of  chronic  suppuration,  they  do  not  usually,  if  ever,  become  a 
source  of  trouble,  and  are  generally  seen  incidentally — that  is, 
when  a  patient's  ear  is  being  examined  for  some  disease  inde- 
pendent of  the  exostosis.  In  these  congenital  cases  the  whole 


486  BONY   GROWTHS. 

calibre  of  the  canal  is  sometimes  lessened  by  a  general  thicken- 
ing of  the  bone,  but  more  frequently  the  growths  extend  from 
one  point,  with  a  pretty  well  defined  pedicle. 

Professor  S.  Moos  '  believes  that  osseous  tumors  in  the  exter- 
nal auditory  canal  are  relatively  frequent,  and  he  has  observed 
three  cases  of  the  symmetrical  formation  of  exostoses  in  both 
auditory  canals,  in  persons  who  consulted  him  for  a  catarrh  of 
the  middle  ear.  "The  tumors  developed  invariably  from  the 
upper  wall  of  the  external  auditory  canal,  close  to  the  drum- 
head, and  opposite  Shrapnell's  membrane."  None  of  the  pa- 
tients had  ever  suffered  from  gout,  rheumatism,  syphilis,  or  a 
suppuration  in  the  ear.  Moos,  thinks  that  these  cases,  were  con- 
sequent upon  irritative  processes  occurring  at  the  time  when  the 
annulus  tympanicus,  unites  with  the  squamous  portion  of  the 
temporal  bone.  Dr.  Gruening  reported  two  similar  cases  at  a 
meeting  of  the  New  York  Ophthalmological  Society,  in  April, 
1872.  These  congenital  bony  growths  do  not  require  treatment, 
and  should  not  be  interfered  with. 

When  the  subject  is  old,  and  the  auditory  canal  is  naturally 
narrowed  by  the  alteration  in  position  in  the  lower  jaw,  some 
trouble  may  be  experienced  from  the  impaction  of  wax  in  the 
ear  in  cases  of  congenital  exostoses,  inasmuch  as  the  usual 
means  of  its  removal — the  motions  of  the  jaw — cannot  produce 
the  same  effect  upon  the  narrow  passage. 

Bonnafont "  reports  an  interesting  case  of  an  aural  exostosis, 
which,  so  far  as  I  can  judge  from  the  history,. which  is  not  very 
detailed  nor  exact,  seems  to  have  been  congenital,  and  to  have 
continued  to  grow  after  birth.  It  completely  obliterated  the 
auditory  canal:  "Observation  d'un  cas  de  surdite  complete  de 
Voreille  gauche  du  a  V obliteration  du  conduit  auditif  par  une 
tumeur  osseuse,  siegeant  pres  la  membrane  du  tympan,  et  guerie 
par  la  trepanation  de  la  tumeur"  There  was  no  history  of  pre- 
vious pain  or  suppuration.  By  the  use  of  a  point  of  nitrate  of 
silver,  for  six  sittings,  the  bone  was  exposed  at  the  centre  of  the 
growth,  and  it  was  then  removed  by  boring  into  it  with  a  rat- 
tail  file.  In  ten  applications  of  this  file,  which  were  not  very 
painful,  an  opening  was  made.  A  whalebone  probe  was  then 
fastened  in  the  opening.  This  opening  was  kept  up  for  some 
months,  and  after  it  was  made  the  tick  of  the  watch  was  heard 
for  some  inches.  Some  years  after,  the  opening  through  the 
exostosis  still  remained. 

1  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  p.  136. 

2  Monatsschrift  fiir  Ohrenheilkunde,  Jahrgang  II.,  No.  8,  lue  a  1'Academie  Im- 
periale  de  Medecine,  May  26,  1868. 


•     BONY   GROWTHS.  487 

Professor  H.  Welcker, '  of  Halle,  in  an  article  upon  bony  growths  in  the  ear, 
found  upon  the  dead  subject,  gives  some  interesting  facts  in  regard  to  these  for- 
mations. Welcker  quotes  from  Seligman,  who  found  exostoses  very  frequently 
in  the  external  auditory  canals  of  the  skulls  of  American  Indians,  that  had  been 
misshapen  by  pressure  exerted  upon  them  in  infancy.  ' '  Of  six  such  skulls,  five 
were  found  to  have  this  kind  of  exostosis."  Seligman  was  inclined  to  believe 
that  these  growths  were  a  peculiarity  of  race ;  but  Welcker  does  not  agree  with 
him,  because  he  found  them  in  other  Indians  not  of  the  tribe  whose  skulls  were 
examined  by  Professor  Seligmau,  and  whose  bones  had  not  been  changed  by 
pressure.  Welcker  also  adds  that  these  exostoses  are  not  extremely  rare  among 
the  cultured  population  of  Europe,  and  as  shown  by  the  text-books  and  C.  O. 
Weber's  collection,  the  external  auditory  canal  is  a  favorite  position  for  them. 
Welcker  thinks  that  Seligman's  observations  show  that  exostoses  of  the  external 
auditory  canal  are  more  frequent  among  the  Indian  tribes  than  among  the  people 
of  Europe,  although  he  does  not  think  there  is  any  race  peculiarity  in  them. 
The  exostoses  found  by  Seligman,  in  such  relative  frequency  among  North 
American  Indians,  seem  to  plainly  belong  to  the  class  of  congenital  growths 
which  have  been  reported  by  Moos,  Gruening,  and  Agnew ;  but  I  have  no  doubt 
that  their  origin  was,  as  Moos  states,  due  to  some  local  irritation,  which  caused 
,a  proliferation  of  bone. 

Dr.  Victor  Bremer,"  of  Copenhagen,  also  reports  a  case  of  removal  of  an 
exostosis  from  the  auditory  canal.  There  was  a  bony  growth  in  each  ear.  The 
right  canal  was  entirely  closed  by  an  osseous  growth  situated  22  mm.  from  the 
meatus.  A  fine  flexible  saw  was  tried,  and  its  use  given  up.  With  a  pair  of 
scissors  he  then  succeeded  in  cutting  off  a  small  piece  of  the  tumor.  The  dental 
engine,  as  suggested  by  Dr.  Mathewson,  was  then  tried,  but  Dr.  Bremer  feared 
to  continue  it,  fearing  that  he  would  injure  the  niembrana  tympani.  The  scis- 
sors were  again  used,  and  in  a  short  time  he  found  that  he  had  cut  through  the 
tumor  and  the  probe  touched  an  elastic  body.  The  suppuration  was  then  free 
and  the  granulations  were  numerous.  The  granulations  were  touched  with 
nitrate  of  silver.  The  canal  was  kept  open  for  fourteen  days  with  laminaria 
digitata.  In  five  weeks  the  hearing  was  restored.  When  the  hearing  was  com- 
plete, it  was  found  that  an  oblong  opening  4  mm.  long  had  been  made  in  the 
tumor.  This  case  is  so  superficially  reported  that  it  is  impossible  to  say 
whether  the  exostosis  was  congenital  or  acquired.  It  is  more  likely  to  have  been 
the  latter,  and  to  have  been  the  result  of  long-continued  inflammation  of  the 
bony  canal. 

Prof essor  William  Turner3  describes  an  exostosis  of  the  canal,  in  an  adult  male 
skull  obtained  near  Pisaqua,  Peru.  Both  passages  were  nearly  closed  by  hard, 
ivory-like  exostoses.  These  were  pedunculated,  and  on  the  left  side,  when  the 
integument  existed,  they  must  have  blocked  up  the  canal.  The  exostoses  on 
both  sides  grew  upon  that  part  of  the  wall  of  the  canal  formed  by  the  auditory 
plate  of  the  expanded  tympanic  ring.  In  the  adult  skull  of  a  flatheaded 
Chenook  Indian,  from  the  district  of  the  Columbia  River,  Professor  Turner 
found  the  right  external  auditory  canal  partially  closed  by  a  broad-based  exos- 


1  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  171. 

8  American  Journal  of  Otology,  vol.  i.,  p.  228.     Annales  des  Malades  de  1'Oreille. 
Paris,  December  31,  1878. 

*  Journal  of  Anatomy  and  Physiology,  xii.,  part  2,  p.  200. 


488  ACQUIRED   EXOSTOSES. 

tosis,  which  grew  from  the  posterior  wall  formed  by  the  tympanic  plate.  There 
was  also  a  linear-shaped  exostosis  deeper  in  the  canal.  Professor  Turner  ob- 
served narrowing  of  the  external  auditory  canal,  in  several  specimens  of  Peruvian 
skulls  not  artificially  deformed. 

Dr.  C.  J.  Blake,  has  examined  the  skulls  of  the  mound-builders  of  Tennessee, 
from  the  collection  of  the  Peabody  Museum  in  Cambridge,  Mass.  Dr.  Blake 
confirms  Professor  Turner's  opinion  that  the  modification  in  the  shape  of  the 
external  auditory  canal  so  often  found  in  aborigines  of  America  is  not  due  to  the 
artificial  elongation  of  the  skull  induced  in  certain  tribes  by  pressure  in  infancy. 
Dr.  Blake's  attention  was  drawn  to  the  subject  by  the  late  Professor  Jeffries 
Wyman,  who  found  exostoses  of  the  auditory  canal  in  6  out  of  334  Peruvian 
crania.  Dr.  Blake  examined  195  skulls.  In  36.  exostoses  were  found  in  one  or 
both  canals,  as  well  as  nan-owing  of  the  canals.  Fifty  Californian  skulls,  taken 
from  graves  in  the  island  near  Santa  Barbara,  were  measured  for  the  sake  of 
comparison  with  those  of  the  mound-builders.  The  average  vertical  diameter 
was  found  to  be  more  than  a  millimetre  greater  in  the  former,  and  the  antero- 
posterior  diameter  more  than  3  mm.  greater.  Of  108  California  crania,  5  had 
exostoses  in  one  or  both  canals,  and  in  3  of  the  5  a  corresponding  narrowing 
of  the  canal.  Dr.  Blake  does  not  think  there  can  be  any  positive  opinion,  as  yet, 
as  to  the  cause  of  these  exostoses  in  the  aborigines  of  various  countries.  There 
were  no  evidences  of  syphilis,  in  the  bones  of  the  Californians  examined.  He  ' 
has  found  that  the  majority  of  the  cases  of  exostosis,  he  has  seen  in  aural  prac- 
tice "  occurred  in  certain  families,  in  the  male  members  of  successive  genera- 
tions, the  most  marked  instance  being  in  the  three  successive  generations  of  one 
family  in  which  there  is  no  tendency  either  to  gouty  or  rheumatic  disease."  Dr. 
Blake  also  examined  37  skulls  from  mounds  in  Arkansas.  Exostoses  of  the 
auditory  canal  were  found  in  6  of  the  37  skulls.  Careful  search  was  made  for 
evidence  of  syphilitic  disease,  by  examination  of  the  long  bones,  but  none  was 
found.  The  6,  containing  exostoses  came  from  one  mound. 

INFLAMMATORY  OR  ACQUIRED  EXOSTOSES. 

The  cases  of  acquired  exostoses  are  a  much  more  serious 
matter  than  the  congenital  affections  of  the  same  kind.  They 
arise  in  the  course  of  a  chronic  suppuration  of  the  middle  ear  ; 
they  usually  grow  with  more  or  less  rapidity,  and  they  may 
finally  block  up  the  tympanic  cavity  and  cause  retention  of  pus 
with  all  its  fatal  results.  Such  a  case  will  be  found  at  the  close 
of  this  section.  They  are  the  results  of  a  local  irritation,  which 
has  caused  in  the  first  place  a  periostitis,  and  secondarily  an 
enlargement  of  bone.  This  local  irritation  may  be  either  the 
constant  presence  of  pus  on  the  walls  of  the  canal,  or  the  exten- 
sion of  the  inflammation  of  the  lining  membrane  of  the  cavity 
of  the  tympanum,  a  membrane  which  is  essentially  a  periosteum, 
to  the  true  periosteum  of  the  osseous  canal. 

Toynbee,  was  inclined  to  ascribe  great  importance  to  the 
existence  of  a  rheumatic,  gouty,  or  syphilitic  diathesis  in  these 
cases  of  acquired  and  growing  exostoses.  In  his  work  upon  the 


ACQUIRED  EXOSTOSES.  489 

•ear,  he  details  nine  cases  of  bony  growths  in  the  external  audi- 
tory canal,  which  he  evidently  regards  as  an  independent  dis- 
ease, and  he  remarks  that  "they  seem  to  be  the  result  of  a  rheu- 
matic or  gouty  diathesis."  In  1866,  I  published  four  cases l  in 
which  there  was  no  such  diathesis,  but  in  which  the  growths 
were  general  enlargements  of  the  periosteum,  and  of  the  bone 
structure  beneath.  They  were  morbid  growths  consequent  upon 
local  irritation.  A  more  complete  experience  has  substantiated 
this  view.  Besides,  a  careful  examination  of  the  history  of  Mr. 
Toynbee's  cases  causes  the  doubt  to  be  raised  whether  a  diathesis 
had  much  to  do  with  the  formation  of  several  of  them ;  while 
some  of  the  others  probably  belonged  to  the  congenital  form. 
In  Case  III.,  reported  by  Toynbee,  a  discharge  had  existed  from 
the  ear  for  eleven  years.  There  was  a  perforation  of  the  mem- 
brana  tympani.  In  Case  VI.  there  was  also  a  discharge.  In 
Case  VII.  the  exostosis  was  found  to  be  the  base  of  a  polypus. 
In  Case  IX.  there  had  been  a  discharge  from  the  ear  when  the 
patient  was  a  boy.  Nine  cases  are  reported  in  all ;  but  the  his- 
tories are  not  very  fully  given. 

Virchow "  says  that  local  influences  are  in  very  many  cases 
the  exciting  cause.  "Some  have,  indeed,  educed  the  frequent 
cases  where  certain  constitutional  diseases,  especially  rheuma- 
tism, arthritis,  syphilis,  scorbutus,  rachitis,  have  produced  bony 
tumors,  as  being  something  opposed  to  these  local  causes.  Un- 
doubtedly the  field  of  these  conditions  was  formerly  too  ampli- 
fied, and  we  may  say  that  scorbutus  is  now  almost  entirely 
excluded  from  the  list  of  causes,  and  that  the  gouty  enlarge- 
ments of  bone  are  no  growths,  but  only  deposits ;  but  we  cannot 
deny  the  influence  of  the  other  so-called  dyscrasia,  especially  of 
the  rheumatic,  syphilitic,  and  rachitic  diatheses.  In  spite  of 
this,  their  influence  should  not  be  over-estimated." 

Polypi,  are  frequently  found  upon  the  exostoses  that  arise  in 
the  course  of  a  suppuration  in  the  ear.  This  is,  of  course,  proof 
that  the  tissue  beneath  is  one  that  has  been  recently  the  seat  of 
inflammation. 

Dr.  Agnew3  has  seen  quite  a  number  of  cases  of  exostoses 
arising  in  cases  in  which  the  membrana  tympani  was  sound, 
and  which  he  believes  were  due  to  local  irritation  after  birth, 
such  as  the  use  of  instruments  for  the  purpose  of  cleansing  or 
scratching  the  canal,  the  formation  of  furuncles  in  the  same 
part,  and  so  forth. 

The  cases  of  acquired  exostosis,  that  I  have  seen,  with  very 

1  New  York  Medical  Journal,  vol.  ii. ,  p.  424. 

"  Die  Krankhaften  Geschwiilste  II.  Bd.  Halfte  I.,  p.  73  et  seq.  passim. 

3  Verbal  communication,  New  York  Oplithalmological  Society. 


490  EXOSTOSES — -TREATMENT. 

few  exceptions,  arose  in  connection  with  suppuration  in  the 
middle  ear.  In  one  exceptional  case,  the  exostosis  was  so  large 
that  the  condition  of  the  inembrana  tympani  could  not  be  posi- 
tively known,  and,  unfortunately,  I  saw  the  case  but  once. 

From  all  the  evidence  I  can  gather,  I  am  inclined  to  think 
that  all  exostoses  of  the  canal  may  be  finally  traced  to  local  in- 
flammation. Blake's  cases,  in  the  aborigines,  as  well  as  his 
cases  occurring  in  private  practice,  and  my  own,  pretty  thor- 
oughly dispose  of  syphilis  as  a  prominent  cause.  I  do  not  think 
the  evidence  for  a  rheumatic  diathesis  as  a  factor,  has  as  yet 
been  made  tenable.  All  the  cases  of  which  we  have  full  his- 
tories, go  to  sustain  the  view,  first  clearly  and  fully  put  forward 
by  myself,  of  local  irritation  as  the  determining  cause.  To  this 
theory  I  still  adhere.  Troltsch,  in  the  first  edition  of  his  book, 
also  remarks  that  he  usually  considers  the  growth  of  exostoses, 
an  incident  of  catarrh  of  the  tympanum. 

Treatment. — The  treatment  of  exostoses,  unless  they  are  so 
large  as  to  prevent  access  to  the  tympanum,  should  begin  by  a 
treatment  of  the  suppuration  that  has  caused  them  to  appear. 
If  we  cannot  heal  the  perforated  and  ulcerating  membrana  tym- 
pani, as  may  be  the  case,  we  should  keep  the  middle  ear  scrupu- 
lously free  from  pus,  so  that  no  blocking-up  may  occur.  The 
patient  should  be  taught  to  cleanse  the  canal  and  tympanum. 
Small  growths  may  be  painted  with  the  tincture  of  iodine.  If 
the  exostoses  are  large  enough  to  close,  or  nearly  close,  the  canal, 
Mathewson's  operation  for  removal  of  these  growths  by  a -drill 
in  a  dental  engine  should  be  performed.  Dr.  Mathewson  first 
performed  this  operation  upon  Case  VI.,  here  reported,  in  1876.  V 

The  machine  used  was  Elliott's  suspension  dental  engine. 
The  patient  was  under  ether.  The  integument  covering  the 
growth  was  first  removed  by  a  dental  instrument  known  as  a 
sealer.  The  bony  growth  was  then  perforated  at  several  points; 
near  its  centre  with  small  drills  about  one  and  a  half  millimetre 
in  diameter.  The  larger  drills,  2£  to  3  mm.  in  diameter,  were 
next  used  to  enlarge  the  openings.  The  probe,  on  account  of  the 
great  bleeding,  was  the  chief  guide  in  the  operation.  "The  ex- 
cavation was  continued  cautiously,"  says  Mathewson,  "  till  the 
largest  drill — about  three  millimetres  in  diameter — passed  freely 
through  with  room  to  spare."  The  operation  consumed  about 
half  an  hour.  The  purulent  discharge,  that  ensued  was  treated 
by  the  warm  douche  and  a  weak  solution  of  nitrate  of  silver 
subsequently.  The  swollen  and  granulating  soft  tissue  finally 

1  Report  of  the  First  International  Otological  Society,  p.  86.  New  York :  D.  Apple- 
ton  &  Co.,  1877. 


EXOSTOSES — CASES.  491 

shrivelled  and  disappeared,  and  the  discharge  ceased,  with  a  good 
opening,  through  which  the  posterior  and  lower  part  of  the  drum- 
head could  be  seen.  The  hearing  arose  nearly  to  the  normal 
standard.  After  Mathewson's  brilliant  result,  his  operation  was 
generally  adopted.  Field,  of  London,  seems  to  have  had  the 
most  experience  in  the  use  of  the  dental  engine  for  the  removal 
of  exostoses.1  His  results,  justify  all  that  Mathewson  claimed 
for  the  operation. 

Exostoses  seem  to  be  a  much  more  frequent  result  of  aural 
disease  in  England  than  in  this  country ;  at  any  rate,  there  are 
many  more  cases  reported  by  English  experts  than  by  those  of 
the  United  States. 

If  the  membrana  tympani  be  intact,  as  it  is  in  many  cases  of 
bony  growths,  even  in  those  where  there  was  at  one  time  sup- 
puration in  the  tympanum,  the  cases  are  much  easier  to  manage. 
There  being  no  pus  to  rest  upon  them,  they  do  not  usually  grow, 
and  if  the  ear  be  kept  carefully  clean  and  free  from  wax,  they 
need  not  be  interfered  with. 

CASES. 

The  following  cases  will  give  a  fair  idea  of  the  course  of 
bony  growths  that  are  consequences  of  chronic  suppuration  and 
chronic  inflammation : 

CASE.  I.— Mr.  C ,  aged  thirty-nine,  was  seen  in  April,  1864,  in  consulta- 
tion with  Dr.  C.  B.  Agnew,  under  whose  care  he  had  been  for  some  time.  He 
had  lost,  before  coming  under  observation,  the  hearing  of  his  right  ear  by  in- 
flammation and  caries  of  the  middle  and  internal  ear.  Previous  to  the  above 
date,  Dr.  Agnew  bad  removed  a  sequestrum,  consisting  of  the  cochlea  and  semi- 
circular canals,  from  the  depths  of  the  external  auditory  canal  of  the  ear,  and 

thus  terminated  the  inflammatory  action.      In  early  life  Mr.   C had  also 

Buffered  from  "inflammation"  of  the  left  ear,  producing  the  bony  growths  in 
the  external  auditory  canal,  which  render  his  case  the  subject  of  present  de- 
scription. He  now  hears  with  this  ear  a  watch  tick  at  a  distance  of  five  inches. 
In  the  auditory  canal,  near  the  meatus,  are  two  bony  enlargements,  which  rise 
from  the  anterior  and  posterior  walls,  and  project  in  a  conical  form,  so  as  to 
occupy  at  least  three-fifths  of  its  calibre.  These  tumors  have  all  the  physical 
appearance  of  exostoses,  and  seem  to  have  originated  in  periosteal  inflammation. 
They  have  been  steadily  treated  for  many  weeks  by  the  local  application  of  the 
saturated  tincture  of  iodine,  and  certainly  not  diminished  in  size.  Pressure 
upon  them  excites  pain  and  induces  an  increase  of  swelling  in  the  skin  which 
covers  them,  and  thus  temporarily  adds  to  the  deafness.  The  entire  absence  of 
hearing  in  the  fellow-ear,  and  the  failure  of  simple  means  to  render  the  exos- 
toses smaller,  have  suggested  the  propriety  of  some  surgical  operation  for  their 
removal.  Such  a  proceeding  has  been  thus  far  postponed  by  the  occurrence  of 
an  acute  attack  of  inflammation  in  the  parts,  extending  to  the  tympanum,  with 


1  Diseases  of  the  Ear,  p.  57. 


492  EXOSTOSES— CASES. 

symptoms  of  more  than  usual  cerebral  irritation.  From  this  disagreeable  com- 
plication he  has  entirely  recovered  under  Dr.  Agnew's  care. 

His  general  health  being  impaired,  he  went  abroad,  and  while  in  London 
consulted  Mr.  Toynbee,  who  used  bougies,  hoping  to  dilate  the  canal ;  but,  ac- 
cording to  Mr.  C 's  statements,  they  caused  much  pain  and  accomplished 

nothing.  Through  Dr.  Agnew's  courtesy,  I  again  saw  the  patient  in  the  spring  of 
1865,  and  found  that  the  growths  had  so  much  increased  that  only  a  small  probe 
could  be  passed  between  them,  and  the  hearing  more  impaired.  The  patient 
could  still,  however,  hear  the  watch  tick,  but  only  when  laid  on  the  auricle. 

The  patient  whose  case  is  here  given,  died  about  two  years 
after,  of  inflammation  of  the  membranes  of  the  brain,  induced 
by  suppuration  in  the  cavity  of  the  tympanum,  the  pus  not  be- 
ing able  to  find  an  outlet  on  account  of  the  presence  of  exos- 
toses.  Dr.  Agnew  exhibited  the  brain  and  temporal  bones  before 
the  New  York  Pathological  Society.  The  history  of  the  other 
ear  of  this  unfortunate  patient  will  be  found  in  the  section  on 
caries  and  necrosis. 

CASE  n. — A  gentleman,  aged  forty,  whom  I  saw  but  once,  in  June,  1864. 
He  states  that  he  had  a  "  running  "  from  his  right  ear  for  a  number  of  years. 
For  some  two  or  three  years  past  he  had  observed  that  the  ear  was  stopped  up. 
He  was  accustomed  to  remove  the  accumulating  discharge  by  thrusting  in  a 
match  armed  with  cotton.  Thfere  is  seen  a  bony  growth  arising  from  the  pos- 
terior wall  of  the  meatus,  and  involving  the  whole  calibre  of  the  canal,  except  a 
space  large  enough  to  admit  an  ordinary-sized  silver  probe.  Through  this  open- 
ing a  slight  amount  of  purulent  discharge  constantly  makes  its  way.  There  was 
some  hypersemia  of  the  pharynx,  and  there  was  a  small  ulcer  on  one  of  the  ton- 
sils. The  patient  was  in  excellent  general  health,  was  rather  a  free  liver,  and 
said  he  had  constitutional  syphilis  :  but  no  good  evidence  of  its  existence  now 
existed.  The  patient  had  never  had  rheumatism  or  gout. 

CASE  III. — Mr.  S ,  aged  twenty-five,  Connecticut.  February  6,  1865  (a 

patient  sent  to  me  by  Dr.  Alfred  North,  of  Waterbury,  Ct.).  When  the  patient 
was  three  or  four  years  of  age  he  had  scarlet  fever,  at  which  time  his  ears  began 
to  discharge,  and  they  have  continued  to  do  so  at  intervals  ever  since,  with  at- 
tacks of  pain  in  the  ears,  which  sometimes  lasted  for  weeks,  and  prevented  him 
from  any  occupation  for  the  time.  Eight  years  ago  his  ears  were  examined  and 
polypi  discovered,  one  of  which  was  removed  by  caustics.  The  attacks  of  pain 
have  continued  to  occur,  the  discharge  continues,  and  his  healing  is  become 
more  and  more  impaired.  He  is  just  now  suffering  from  acute  pain,  referred  to 
the  left  ear.  He  hears  the  watch  about  one  inch  from  each  ear. 

In  the  right  meatus  there  is  seen  a  bony  growth  reaching  nearly  out  of  the 
orifice  of  the  external  meatus,  and  arising  from  the  posterior  wall.  The  space 
between  the  growth  and  the  anterior  and  upper  wall  is  about  large  enough  to  ad- 
mit of  the  introduction  of  a  camel's-hair  brush.  In  the  left  meatns  there  is  seen 
a  gelatinous  granulation,  also  reaching  nearly  out  to  the  orifice  of  the  meatus. 

On  blowing  air  into  the  cavity  of  the  tympanum,  by  means  of  the  Eustachian 
catheter,  air  and  fluid  are  heard  making  their  exit  into  the  external  meatus  ;  but 
the  blocking  up  of  this  passage  prevents  their  emergence.  On  the  right  side 


EXOSTOSES — CASES.  493 

pus  may  be  seen  in  the  orifice  between  the  bony  growth  and  the  wall  of  the 
meatus. 

The  confinement  of  the  fluid  in  the  middle  ear  accounts  for  the  pain  in  the 
left  side,  and  the  indication  of  treatment  was  to  secure  its  free  exit.  This  was 
done  by  removing  the  gelatinous  growth  by  torsion,  the  patient  being  ether- 
ized, and  rendering  the  Eustachian  tubes  permeable  by  the  use  of  the  well- 
known  means — the  catheter  and  Politzer's  method.  The  granulation  was  found 
to  have  its  origin  from  a  general  bony  expansion  of  the  meatus.  This  growth 
had  no  one  point  of  attachment,  but  involved  all  the  sides  of  the  meatus, 
somewhat  more  expanded  externally,  giving  the  bony  canal  rather  a  funnel- 
shaped  appearance.  The  bone  was  roughened.  The  pain  in  the  ear  disappeared 
as  soon  as  these  means  had  been  taken  for  securing  an  outlet  to  the  pus,  con- 
stantly secreted  from  the  cavity  of  the  tympanum,  and  passing  through  the  per- 
forated membrana  tympani,  and  the  hearing  was  so  much  improved  that  the  watch 
was  heard  about  four  inches  from  the  left  auricle.  He  remained  under  treat- 
ment for  a  few  days,  and  then  returned  to  Waterbury,  and  has  been  under  the 
careful  and  able  observation  of  Dr.  North,  who  has  applied  remedies  of  various 
kinds  to  the  left  meatus,  the  patient  keeping  the  Eustachian  tubes  permeable 
by  means  of  gargles  and  Politzer's  apparatus.  The  last  time  I  saw  the  patient 
was  in  October  of  this  year  (1865),  when  the  following  note  was  made :  "He  had 
had  no  attack  of  pain  in  the  ear  since  the  first  date.  There  is  still  a  consider- 
able discharge  of  pus  from  each  ear.  He  hears  ordinary  conversation  well,  and 
the  watch  ten  inches  from  his  left  ear,  and  two  inches  on  the  right ;  a  gain  of 
one  inch  and  nine  inches  respectively."  The  bony  growth  on  the  right  side  has 
not  increased  any,  and  that  on  the  left  is  now  smooth,  and  has  a  somewhat 
glistening  appearance.  June,  1868. — Patient  still  remains  free  from  any  disturb- 
ing symptoms. 

Dr.  North  writes  me,  March  25,  1873,  that  "the  patient's  general  health  is 
good.  He  hears  ordinary  conversation  readily,  and  Dr.  North's  watch  eight  and 
one-half  inches  from  the  left  auricle  and  one  and  one-half  from  the  right.  The 
bony  growth  has  a  smooth,  shiny  appearance,  and  only  admits  the  passage  of  an 
ordinary-sized  probe.  The  discharge  from  the  ear  is  slight  and  of  a  watery 
nature.  He  has  no  pain  in  either  ear.  Any  increase  of  the  impairment  of 
hearing  is  always  relieved  by  an  application  of  tincture  of  iodine  to  the  bony 
growths." 

CASE  IV. — Woman,  aged  twenty-seven,  at  the  New  York  Eye  and  Ear  Infirm- 
ary. No  reliable  history  could  be  obtained  from  the  patient  as  to  her  ears, 
except  that  she  had  been  occasionally  hard  of  hearing  for  some  years.  She  was 
quite  sure  that  she  never  had  had  a  discharge  from  the  ears ;  was  in  good  gen- 
eral health,  and  had  always  been  so.  She  could  hear  the  watch  two  feet  from 
the  left  auricle,  and  twelve  inches  from  the  right.  The  left  membrana  tympani 
showed  evidences  of  previous  inflammatory  action,  there  being  thickening  of  its 
mucous  and  fibrous  layers.  There  is  a  bony  enlargement  of  the  posterior  wall 
of  the  right  meatus,  so  large  as  to  prevent  any  view  of  the  membrana  tympani. 
The  patient  was  seen  but  a  few  times,  not  contimiing  under  treatment. 

CASE  V. — Mr.  W ,  aged  twenty -three,  a  patient  sent  to  me  by  Professor 

Fordyce  Barker,  of  this  city.  Had  scarlet  fever  when  young,  and  since  that 
time  has  suffered  from  purulent  discharge  from  the  ear,  and  has  been  quite  deaf. 


494  EXOSTOSES — CASES. 

General  health  is  excellent.  No  gouty,  rheumatic,  or  other  diathesis.  Hears 
ordinary  conversation  very  near  at  hand  with  very  great  difficulty.  The  watch 
is  heard  when  pressed  upon  the  right  meatus  ;  not  at  all  on  left.  A  gelatinous 
polypus  was  found  attached  to  the  hypertrophic  posterior  wall  of  the  auditory 
canal.  It  was  removed  by  torsion,  and  nitric  acid  applied  to  its  roots.  On  left 
side  there  is  a  pedunculated  bony  growth,  arising  from  the  posterior  wall,  nearly 
occluding  calibre  of  canal.  Naso-pharyngeal  catarrh.  June,  1868. — Patient  has 
been  under  observation  since  first  date.  Now  hears  conversation  much  better ; 
watch  at  a  distance  varying  from  one  to  two  inches  on  right  side.  Secretion  of 
pus,  which  when  patient  was  first  seen  was  profuse,  is  now  slight.  Growths 
remain  the  same. 


CASE  VI. — Miss ,  aged  twenty-five.  March,  1873.  I  was  asked  by  Dr. 

E.  G.  Loring  to  assist  him  in  the  examination,  under  ether,  of  a  case  of  tumor 
blocking  up  the  external  auditory  canal,  with  a  view  to  its  removal  if  practicable. 
The  tumor  was  so  sensitive  to  the  touch  of  a  probe  that  no  thorough  examina- 
tion could  be  made.  The  patient  was  about  twenty-five  years  of  age,  and  had 
suffered  a  great  deal  from  what  she  called  rheumatism  of  the  back,  but  which 
seemed  to  have  been  neuralgia.  She  was  rather  small  and  delicate,  but  in  fair 
general  health.  She  was  placed  under  the  influence  of  ether,  and  a  thorough 
examination  was  made  by  Dr.  Loring,  Dr.  Pardee,  and  myself.  The  tumor 
arose  from  the  posterior  portion  of  the  osseous  canal  of  the  right  ear,  and  nearly 
occluded  the  passage.  There  was  a  minute  opening  between  it  and  the  anterior 
wall,  through  which  a  No.  2  Bowman's  probe  could  be  passed  into  the  cavity  of 
khe  tympanum.  The  tumor  was  of  bone,  and  covered  by  a  movable  integument, 
which  was  red  and  very  sensitive.  On  passing  the  probe  into  the  minute  open- 
ing that  has  been  mentioned,  it  could  be  passed  under  the  growth,  and  when 
pressed  upon  the  growth  was  seen  to  move  slightly. 

The  history  of  the  case  was,  that  there  were  frequent  attack*  of  pain  in  the 
ear,  without  discharge,  until  the  patient  was  eleven  years  old,  since  which  time 
there  has  been  no  true  "earache,"  and  no  discharge,  although  the  parts  are 
tender,  and  there  is  a  great  feeling  of  fulness  in  the  ear.  The  watch  is  not 
heard  at  all  on  the  affected  side.  The  tuning-fork  is  heard  better  than  in  the 
other  ear,  which  is  normal.  The  examination,  during  the  anaesthetic  state,  of 
the  tumor  by  the  probe,  caused  it  to  be  very  sensitive  when  the  patient  recov- 
ered from  the  ether.  The  aural  douche  was  used  to  quiet  the  pain.  The  pa- 
tient was  advised  to  continue  to  use  the  douche  ;  but  inasmuch  as  there  was  no 
pus  in  the  tympanic  cavity,  and  the  removal  of  the  growth  seemed  to  involve 
considerable  danger  from  periostitis,  any  further  treatment  was  delayed  until 
urgent  symptoms  should  arise.  May  8,  1873. — There  is  considerable  pain  in  the 
depth  of  the  ear,  and  Dr.  Loring  and  I  advise  that  some  operative  means  be 
taken  to  remove  the  growth. 

The  history  of  this  case  indicates  that  there  was  originally 
a  suppurative  action,  for  we  can  hardly  believe  that  very  severe 
pain  occurred  so  frequently  as  was  stated,  until  the  patient  was 
eleven  years  old,  with  no  suppuration.  The  exostosis,  which 
probably  then  began,  has  been  growing  ever  since,  until  it  has 


EXOSTOSES — CASES.  495 

reached  the  present  limits,  where  it  seriously  threatens  the  fu- 
ture of  the  patient. 

The  danger  which  seemed  to  exist,  when  I  wrote  the  fore- 
going paragraph,  was  happily  averted  by  Dr.  Mathewson's  first 
operation  with  the  dental  engine.  The  case  came  into  his  hands 
in  1876,  and  he  devised  and  executed  a  method  of  removing 
these  bony  growths,  which  as  yet  remains  the  best  that  has  ever 
been  suggested  or  performed. 

CASE  VII.— October  23,   1883.     Miss  ,  aged  twenty-one.     When  seven 

years  of  age  she  had  scarlet  fever  ;  both  ears  discharged  excessively  during  the 
progress  of  the  disease.  Had  loss  of  motion  of  the  right  side  for  thirteen 
months  after.  The  left  ear  still  discharges.  There  is  no  aerial  conduction  on 
the  right  side  and  the  bone  conduction  is  better  than  the  aerial  on  the  left  side. 
Hears  the  voice  about  one  foot  from  the  left  side.  There  is  a  bony  growth  in 
the  left  auditory  canal,  arising  from  the  posterior  wall  and  about  half  closing  the 
opening  into  the  tympanum.  There  is  no  drum-head  in  either  ear. 

CASE  VIII. — March  6,  1884.     Mr.  A.  J ,  aged  thirty-eight  (sent  to  me  by 

Dr.  Jones,  of  Chicago).  When  the  patient  was  eighteen  years  old,  the  left  ear 
was  injured  by  the  explosion  of  a  cannon  near  his  ear.  He  was  thrown  into  the 
water,  and  did  not  think  of  his  ear  for  a  day  or  two.  He  then  observed  that  he 
could  not  hear  well.  His  ears  have  never  been  quite  right  since,  especially 
at  times.  His  hearing  distance  is:  E.,  ^;  L.,  £g.  The  tuning-fork  is  heard 
much  better  in  each  ear  by  bone  conduction.  There  are  small  bony  growths  aris- 
ing from  the  anterior  wall  of  both  auditory  canals.  The  membranse  tympani  are 
opaque  on  each  side.  The  patient  was  not  sure  as  to  whether  he  had  ever  had 
a  suppuration  in  his  ears.  He  had  chronic  naso-pharyngeal  catarrh  as  well  as 
a  decided  inflammation  of  the  middle  ears.  There  was  no  evidence  of  the  ex- 
istence of  either  syphilis,  gout,  or  rheumatism. 

Dr.  Cocks  reports  '  an  interesting  case  of  a  pedunculated  bony 
growth  in  the  auditory  canal,  which  formed  the  base  of  a  poly- 
pus. It  was  so  like  a  polypus  in  appearance,  that  a  snare  was 
put  about  it,  and  it  was  fortunately  broken  off.  The  growth 
sprang  from  the  posterior  wall  of  the  canal,  at  the  junction  of 
the  osseous  and  cartilaginous  portions. 

'Archives  of  Otology,  vol.  xii.,  p.  59. 


CHAPTER   XVIII. 

THE  CONSEQUENCES  OF  CHEONIC  SUPPUKATION  OF  THE 
MIDDLE   EAR— (Continued). 

DISEASES  OP  THE  MASTOID  PROCESS. 

Periostitis. — Caries    and  Suppuration. — Trephining   or  Opening  the  Mastoid. — His- 
torical Account  of  the  Operation. — Cases. 

As  we  have  seen,  in  considering  the  diseases  of  the  middle  ear, 
and  in  discussing  its  anatomy,  the  mastoid  process  is  necessarily 
involved  in  any  severe  inflammation  of  the  tympanum.  This 
may  also  be  the  case  in  an  acute  or  chronic  inflammation  of 
the  auditory  canal,  for  the  mastoid  process  opens  into  this  part 
also.  Yet  there  is  a  form  of  inflammation  of  the  mastoid  pro- 
cess, which  assumes  such  importance,  and  overshadows  the  in- 
flammatory action  in  other  parts,  to  such  a  degree,  that  it  de- 
mands an  especial  study,  and  especial  treatment.  The  usual 
treatment  of  an  acute  inflammation  of  the  external  and  middle 
ear  soon  causes  the  symptoms  of  the  inflammation  of  the  lining 
membrane  of  the  mastoid  cavities  to  subside ;  but  when  the 
mastoid  process  is  involved  in  the  course  of  a  chronic  suppu- 
rative  process,  the  ordinary  treatment  will  not  avail.  More 
prompt  and  decisive  means  are  usually  required.  Under  such 
circumstances,  diseases  of  the  mastoid  often  assume  such  pro- 
portions of  severity  and  danger,  that  we  are  justified  in  speak- 
ing of  them  as  independent  affections  requiring  especial  notice 
and  treatment.  Severe  disease  of  the  mastoid  is  a  complication 
or  consequence  of  chronic  suppuration  in  the  middle  ear,  only 
second  in  gravity,  to  an  extension  of  the  inflammation  to  that 
portion  of  the  dura  mater  covering  and  running  into  the  tym- 
panic cavity. 

The  diseases  of  the  mastoid  process  that  may  arise  as  a  con- 
sequence of  a  chronic  inflammation  of  the  middle  ear  may  be 
divided  into  the  following  varieties  : 

1.  Inflammation  of  the  periosteum. 

2.  Caries,  with  formation  of  an  abscess  in  some  part  of  the 
cavity. 


MASTOID   PERIOSTITIS.  497 

It  is  true,  as  has  been  already  indicated,  that  the  first  form 
often  arises  in  the  course  of  an  acute  catarrh,  and  that  it  perhaps 
always  exists  to  a  more  or  less  extent  in  this  disease ;  but  it  is 
no  less  true  that  a  chronic  suppurative  process  that  has  been  go- 
ing on  quietly  for  years  perhaps,  will  suddenly  become  an  acute 
inflammation  of  the  mucous  membrane  and  periosteum  of  the 
part,  and  require  especial  and  prompt  treatment.  The  mucous 
membrane  lining  the  mastoid  cells  is  so  closely  connected  to  the 
bone,  that,  like  the  mucous  membrane  of  the  cavity  of  the  tym- 
panum, it  is  essentially  a  periosteum. 

Caries  and  necrosis,  a,re  of  course  the  same  affections  that 
occur  so  frequently  in  other  parts  of  the  middle  ear,  and  from 
the  same  cause — imperfect  removal  of  pus. 

Sclerosis  or  hyperostosis  should  also  be  mentioned  as  one  of 
the  results  of  chronic  inflammation  of  this  part.  During  the 
operation  for  perforation  of  the  mastoid  it  is  often  found,  as 
shown  by  Agnew's  case,1  and  subsequently  by  Buck's1  and 
Schwartze's 3  statistics,  in  a  state  of  sclerosis.  Anatomical  inves- 
tigations indicate,  that  this  is  oftener  a  congenital  rather  than  a 
pathological  condition.  If  the  bone  is  not  pneumatic,  it  is  cer- 
tainly in  a  worse  condition  for  the  reception  of  a  chronic  inflam- 
matory process,  than  if  it  were  full  of  air-cells. 

Disease  of  the  mastoid  is  usually  seen  in  plain  connection 
with  an  affection  of  the  tympanum.  In  the  nature  of  things 
this  must  necessarily  be  so,  for  the  mastoid  process  and  the 
tympanum  are  merely  parts  of  one  anatomical  space,  and  no 
complete  separation  of  their  inflammations  is  possible.  But  this 
is  not  always  so.  A  few  weeks  ago,  I  evacuated  a  drachm  or 
more  of  pus  from  the  mastoid  cells  of  a  young  child,  through  the 
auditory  canal,  while  the  membrana  tympani  remained  intact  and 
apparently  uninjured.  The  patient  made  a  good  recovery,  and 
although  I  could  not  determine  on  account  of  the  patient's  age 
— she  was  about  three  years  old — whether  or  not  there  was  a 
catarrh  of  the  tympanum,  there  was  certainly  no  serious  inflam- 
mation except  in  the  mastoid.  It  was  markedly  red,  swelled, 
and  tender.  From  the  history,  given  by  the  child's  mother,  I 
do  not  doubt,  that  the  case  was  one  of  suppuration  of  the  mid- 
dle ear,  especially  affecting  the  mastoid  portion  of  this  part. 
Other  cases  of  so-called  primary  periostitis  have  been  published,4 


1  Transactions  of  the  American  Otological  Society,  July  20,  1870. 

8  Treatise  on  the  Ear. 

3  Archiv  fur  Ohrenheilkunde,  Bd.  IV.-XX.,  passim. 

4Knapp:    Report  of  International  Otological  Congress,    Xew  York,   1876,   p.   80. 
Gruening:    Medical  Record,  June  4,  1881.     Cornelius  Williams:    Archives  of  Otology, 
vol.  xiii.,  p.  22.     W.  Cheatham:  Louisville  Medical  Journal,  October  26,  1878. 
32 


498  MASTOID   PERIOSTITIS. 

but  a  careful  reading  of  the  histories  shows  that  while  the  per- 
iosteum of  the  mastoid,  was  undoubtedly  more  severely  affected 
than  the  lining  membrane  of  the  other  parts  of  the  middle  ear, 
it  is  by  no  means  certain  that  the  mastoid  inflammation  was  not 
actually  secondary  to  that  of  the  tympanum,  although  the  latter 
may  have  run  its  course,  by  the  time  the  former  was  under  full 
headway.  Buck J  also  doubts  if  we  may  correctly  speak  of  a 
primary  periostitis  of  the  mastoid  process.  He  says  that  he  has 
never  seen  a  case,  to  which  he  would  feel  justified  in  giving  the 
title  of  primary  idiopathic  mastoid  periostitis.  Buck  explains 
the  cause  of  the  apparently  primary  cases  of  mastoid  disease, 
occurring  in  young  children,  as  I  do,  in  supposing  that  the  pus 
from  the  tympanum  found  an  easier  escape  through  the  mastoid 
than  through  the  membrana  tympani.  Mastoid  periostitis,  as 
well  as  caries  and  abscess,  are  usually  results  of  disease  of  the 
Eustachian  tube  and  the  tympanum. 

Symptoms. — The  symptoms  of  mastoid  periostitis  are  usually 
so  distinct  as  to  arrest  the  attention  of  the  medical  adviser  as 
soon  as  they  occur. 

During  the  course  of  an  acute  or  chronic  suppurative  process 
in  the  middle  ear,  the  patient  begins  to  complain  of  great  pain 
behind  the  ear,  the  mastoid  process  becomes  red,  tender,  and 
swelled.  This  is  the  usual  course,  although  at  times  the  pain  is 
not  referred  especially  to  the  mastoid,  even  when  it  is  evidently 
involved,  as  shown  by  the  redness  or  tenderness  of  the  part. 
The  pain  is  usually  of  the  severest  kind,  preventing  the  patient 
from  sleep  and  from  his  usual  occupations,  although  he  may  not 
be  confined  to  the  house. 

One  of  my  cases,  reported  on  a  subsequent  page,  as  well  as 
others,  shows  that  an  inflammatory  process  may  extend  to  the 
periosteum  of  the  mastoid,  without  pain  or  tenderness  of  this 
part,  but  there  are  then  symptoms  in  other  parts  of  the  skull, 
especially  in  the  occiput,  which  considered  in  connection  with 
the  inflammation  of  the  middle  ear,  will  keep  the  surgeon  on  his 
guard.  Besides,  these  cases  are  entirely  exceptional. 

The  early  diagnosis  of  this  affection  is  by  no  means  an  un- 
important matter.  A  delay  in  the  recognition  of  the  true  state 
of  things,  allows  of  the  extension  of  the  disease  to  the  brain 
through  some  of  the  numerous  foramina  which  transmit  the 
minute  branches  of  the  middle  meningeal  artery.  Pus  may 
also  be  carried  into  the  circulation  through  the  mastoid  vein 
which  passes  to  the  lateral  sinus. 


1  Diseases  of  the  Ear,  p.  355. 


MASTOID   PERIOSTITIS.  499 

Dr.  One  Green '  has  shown,  by  the  report  of  three  cases,  that 
phlebitis  of  the  emissory  veins  of  the  mastoid  may  occur  in  the 
course  of  inflammation  of  the  middle  ear  and  lateral  sinus 
oftener  than  has  yet  been  observed.  Dr.  Green  quotes  cases 
from  Kolb,  Taylor,  Moos,  and  Burchardt-Merian,  which  indi- 
cate this. 

In  Green's  cases,  the  phlebitis  was  due  to  an  extension  of  an 
inflammation  of  the  lateral  sinuses.  In  all  of  the  cases  the 
"prominent  and  characteristic -symptom  was  the  peculiar  indu- 
ration of  the  tissues  of  the  neck,  such  as  characterizes  a  cellulitis 
dependent  upon  phlebitis,  and  one  of  the  best  examples  of  which 
is  seen  in phlegmasia  alba  dolens."  Death  occurred  in  all  of  Dr. 
Green's  cases.  In  one  of  them,  so  far  as  could  be  determined 
by  the  history,  there  was  no  external  periostitis,  but  no  autopsy 
could  be  obtained  in  any  of  the  cases.  It  is  probable  that  phle- 
bitis of  the  emissory  veins  is  more  frequently  a  consequence  of 
disease  of  the  mastoid  process  than  has  hitherto  been  supposed. 

Professor  Alfred  C.  Post,  of  this  city,  who  was  one  of  the 
first  surgeons  in  this  country  to  give  diseases  of  the  ear  the 
same  attention  that  was  paid  to  other  parts  of  the  body,  has 
seen  several  cases  where  disease  of  the  brain  and  death  have  re- 
sulted from  the  non-recognition  of  mastoid  disease,  as  I  learned 
from  his  lectures  during  the  sessions  of  1856-59. 

Many  neglected  cases  run  their  course,  however,  with  great 
suffering  to  the  patient,  and  with  much  loss  of  function,  with- 
out destroying  life.  This  is  proven  by  the  frequency  with  which 
mastoid  cicatrices  are  seen  in  our  aural  clinics.  The  history  of 
such  patients  usually  shows  that  they  have  had  a  narrow  es- 
cape, but  that  nature  has  at  last  given  relief  by  an  external 
opening  through  which  the  pus  and  dead  bone  made  their  way. 

Treatment. — The  treatment  of  mastoid  congestion  and  peri- 
ostitis* is  very  simple.  If  the  symptoms,  although  positive,  be 
of  a  mild  type,  from  two  to  six  leeches  should  be  placed  upon 
the  mastoid.  After  the  bleeding  has  subsided,  a  poultice  should 
be  applied.  The  patient  should  be  kept  in-doors  and  in  bed.  If 
the  pain  and  tenderness  are  not  relieved  in  twenty-four  hours, 
an  incision  should  be  made  through  the  integument  and  perios- 
teum down  to  the  bone.  The  incision  should  be  from  below 
upward,  lest  the  knife  should  slip  and  pass  into  the  tissues  of 
the  neck.  The  opening  should  not  be  a  puncture,  but  a  cut  of 
from  three-quarters  to  an  inch  and  a  half  long,  or  even  longer, 
according  to  the  age  of  the  subject.  The  incision  should  be 


American  Journal  of  Otology,  p.  187.    1879. 


500  WILDE'S  INCISION. 

parallel  to  the  attachment  of  the  auricle.  Even  if  the  posterior 
auricular  artery  be  wounded,  the  bleeding  can  be  readily  ar- 
rested by  pressure  or  torsion.  I  have  never  found  any  alarming 
hemorrhage.  A  free  escape  of  blood  is  desirable.  The  surgeon 
who  has  not  made  this  incision  in  cases  of  mastoid  periostitis 
will,  perhaps,  be  surprised  at  the  depth  of  the  tissues  when  they 
have  become  infiltrated  from  an  inflammatory  action  of  some 
days'  standing.  I  have  sometimes  been  amazed  at  the  depth  to 
i  which  the  scalpel  entered,  especially  when  pus  has  formed.  Pus 
will  not  be  found  in  the  majority  of  the  cases,  but  the  indica- 
tions for  an  early,  free,  and  deep  incision  are  imperative  when 
we  find  redness,  tenderness,  and  swelling  of  the  mastoid  process 
in  connection  with  an  inflammatory  process  in  the  ear. 

It  is  only  when  the  symptoms  are  not  severe,  although  posi- 
tively existing,  that  a  little  delay,  that  is  of  a  few  hours,  may 
be  admissible  for  the  use  of  leeches,  and  the  careful  continuous 
application  of  poultices.  If  the  symptoms  are  decidedly  ameli- 
orated in  a  few  hours,  still  further  delay  is  justifiable.  This,  it 
should  be  said,  however,  is  only  true  of  cases  of  a  mild  type. 

In  view  of  the  dangerous  character  of  mastoid  periostitis,  it 
will  be  better  to  err  on  the  side  of  a  free  and  thorough  incision, 
the  so-called  Wilde's  incision,  from  Sir  William  Wilde,  who  first 
advised  it, — than  to  be  too  late  in  other  cases.  The  cases  that 
have  been  reported  as  recovering  without  the  knife  and  from 
internal  medication,  by  the  use  of  such  drugs  as  the  sulphide 
of  calcium,  are,  in  my  opinion,  cases  such  as  have  recovered 
in  my  hands,  as  well  as  in  those  of  my  colleagues  at  the  Man- 
hattan Eye  and  Ear  Hospital,  without  any  drugs  whatever.  To 
keep  a  patient  in  bed,  and  in  a  quiet  room,  with  proper  ventila- 
tion and  warmth,  and  besides  to  nourish  him  well,  and  to  use 
poultices  and  the  warm  douche,  is  to  institute  a  very  thorough 
treatment  for  many  diseases  of  the  ear.  Beyond  these  means, 
in  many  cases  nothing  is  required — and  without  them  nothing 
whatever  can  be  accomplished. 

Although  I  have  classified  periostitis  and  caries  of  the  mas- 
toid, among  the  consequences  of  chronic  suppuration,  it  goes 
without  saying,  that  it  sometimes  arises  in  the  course  of  acute 
and  primary  disease.  It  should  also  be  understood  that  when  it 
occurs  in  chronic  suppuration  the  acute  symptoms  also  affect 
the  tympanum. 

There  is  a  phlegmonous  inflammation  of  the  skin  and  connec- 
tive tissue  over  the  mastoid,  especially  in  young  subjects,  gener- 
ally arising  from  disease  of  the  auditory  canal,  which  is  never 
serious,  although  painful.  A  little  experience  in  the  differential 
diagnosis  of  diseases  of  the  middle  and  external  ear,  will  soon 


MASTOID   PERIOSTITIS — TREATMENT.  501 

enable  the  practitioner  to  distinguish  these  harmless  cases  of 
swelling  and  tenderness  of  the  skin  and  connective  tissue  of 
the  mastoid  from  periostitis.  Furuncles,  and  other  inflamma- 
tions in  the  auditory  canal  may  cause  an  oadema  and  inflam- 
mation of  the  parts  about  the  mastoid,  that  will  not  require  an 
incision.  A  little  care  in  observation  will  show,  however,  that 
while  these  cases  simulate  a  periostitis  in  the  swelling  and  red- 
ness, there  is  not  the  exquisite  tenderness  and  dreadful  suffer- 
ing of  a  true  periostitis.  The  mastoid  gfcand  may  enlarge  during 
the  course  of  an  acute  catarrh,  or  in  strumous  subjects  who 
have  no  aural  disease,  but  such  an  enlargement  will  hardly  be 
mistaken  for  a  periostitis. 

If  the  incision.be  made  in  the  early  stages  of  mastoid  peri- 
ostitis, pus  will  not  be  found,  but  the  relief  to  the  pain  from  the 
hemorrhage,  and  from  the  letting  up  of  the  great  tension  of 
the  inflamed  periosteum,  will  be  no  less  marked  than  if  sup- 
puration has  occurred.  The  incision  will  be  as  useful  as  the  di- 
vision of  the  periosteum  in  a  case  of  paronychia — a  comparison 
which  Dr.  Post  has  been  in  the  habit  of  making  in  lecturing 
upon  these  cases. 

After  the  incision,  a  poultice  should  be  applied,  and  the  open- 
ing maintained  by  the  insertion  of  a  tent  a  longer  or  shorter 
time,  according  to  the  severity  of  the  accompanying  symptoms. 
The  importance  of  maintaining  the  opening  for  some  time  in 
cases  of  chronic  suppuration,  was  very  well  illustrated  by  the 
following  case  : 

In  June,  1872,  I  saw  in  consultation  with  Dr.  E.  G.  Loring,  a 
somewhat  remarkable  case  of  chronic  suppuration  in  the  middle 
ear,  with  mastoid  periostitis,  in  a  gentleman  of  more  than  seventy 
years  of  age,  in  which  the  opening  was  maintained  by  Dr.  Lor- 
ing, by  means  of  trimming  up  the  edges  with  scissors,  the  use 
of  caustic,  a  drainage-tube,  and  so  forth,  for  some  three  months. 
Dr.  Loring  found  that  the  instant  the  opening  was  allowed  to 
close,  pain  in  the  back  of  the  head,  and  in  the  depth  of  the  ear, 
began  to  recur,  which  threatened  even  the  life  of  the  old  gentle- 
man who  was  the  subject  of  the  disease.  The  patient  finally 
made  a  perfect  recovery  from  the  mastoid  disease,  and  he  is  ac- 
tvely  engaged  in  the  daily  care  of  large  business  affairs.  The 
mastoid  periostitis  in  his  case  was  a  consequence  of  an  un- 
usually severe  acute  suppuration  of  the  middle  ear,  which 
swept  away  the  drum-head  in  a  short  time. 

The  treatment  of  the  greater  number  of  cases  of  periostitis  is 
not  usually  so  tedious  as  the  case  just  reported.  With  the  inci- 
sion and  a  few  hours  of  poulticing,  if  the  bone  be  not  diseased, 
the  acute  symptoms  subside  very  rapidly,  and  the  patient  is  soon 


502  MASTOID   PERIOSTITIS — CASES. 

about  his  usual  affairs.  Although  patients  are  generally  to  be 
confined  to  their  room,  or  house  at  least,  during  the  time  of  the 
acute  symptoms,  some  of  them  go  about  enough  to  visit  the  sur- 
geon at  his  consulting-room,  especially  in  the  spring  weather, 
and  with  no  bad  results. 


CASES. 

CASE  I. — Periostitis  of  the  Mastoid  from  Acute  Suppuration — Recovery  without 
Incision. — B.  S ,  aged  nineteen.  July  25,  1884.  One  week  ago,  after  bath- 
ing he  had  pain  in  his  right  ear,  which  has  continued  at  intervals.  He  now  has 
severe  pain  referred  to  the  forehead  and  the  neck.  The  patient  is  thin  and 
haggard.  H.  D.,  B.,  -£$;  L.,  to-  The  bone  conduction  is  better  than  the  aerial 
in  the  right  ear,  and  the  reverse  is  true  of  the  sound  ear.  Eight  auditory  canal 
swelled.  Eight  membrana  tympani  swelled  and  red.  There  is  tenderness  over 
the  whole  surface  of  the  mast-old  and  down  into  the  neck.  On  inflation  the 
hearing  distance  of  the  ear  increased  to  3—-.  The  patient  was  seen  by  nay  asso- 
ciate, Dr.  J.  B.  Emerson,  in  consultation  with  Dr.  Fisher,  of  Hoboken.  It  was 
agreed  that  the  patient  be  put  to  bed.  Two  leeches  were  applied  to  the  niastoid- 
The  hot  douche  was  ordered  to  be  used  every  two  hours,  and  poultices  were  applied 
in  front  and  behind  the  auricle.  The  patient  began  to  be  more  comfortable  at 
once.  The  drum-head  perforated  spontaneously  on  the  third  day.  On  the 
fourth  day  he  was  up,  with  no  pain  except  at  long  intervals.  In  eleven  days  the 
drum-head  had  healed,  and  in  twenty  days  the  patient  was  practically  well 
(H.  D.,  $8)1  and  he  left  town  for  the  country. 

CASE  II. — Periostitis  of  Mastoid  occurring  during  an  Exacerbation  in  a  Case  of 

Chronic  Suppuration  of  both  Middle  Ears — Recovery  without  Incision. — J.  L.  S , 

aged  twenty-six.  Farmer.  February  21, 1883.  Ten  years  ago  he  had  the  small- 
pox, which  left  him  somewhat  hard  of  hearing.  Five  years  ago  he  had  a  severe 
cold,  which  very  much  increased  the  trouble.  During  January  of  this  year,  he 
had  the  measles,  with  severe  pain  in  both  ears,  and  a  purulent  discharge  from 
the  left.  There  was  also  a  slight  swelling  of  each  mastoid,  but  it  disappeared 
in  about  four  days.  One  week  ago  this  swelling  returned.  Each  mastoid  process 
is  swelled  and  tender.  Both  drum-heads  are  perforated,  but  neither  discharges 
freely.  No  aerial  conduction  in  either  ear.  The  patient  was  seen  at  my  office, 
but  he  was  advised  to  go  to  the  hospital,  which  he  did.  He  was  then  put  to 
bed,  two  leeches  were  applied  to  each  mastoid,  and  the  hot  douche  was  used 
often.  The  next  day  the  tenderness  of  the  mastoid  was  markedly  diminished. 
The  poultices  and  hot  douche  were  continued,  and  in  eleven  days  he  was  free 
from  all  pain  and  tenderness  about  the  ears. 

These  cases  illustrate  very  well,  how  with  circumspection,  we 
may  sometimes  substitute  leeches  and  poultices,  for  Wilde's  in- 
cision and  poultices. 

The  two  first  of  the  following  cases  are  from  the  notes  of  Dr. 
David  Webster,  when  he  was  House  Surgeon  in  the  Brooklyn 
Eye  and  Ear  Hospital,  where  they  were  under  my  care,  and  are 


MASTOID    PERIOSTITIS  —  CASES.  503 

striking  evidences  of  the  prompt  relief  afforded  by  timely  inter- 
ference : 

CASE  III.  —  Chronic  Suppurative  Otitis  Media  —  Cessation  of  Discharge  —  Mastoid 
Periostitis  —  Incision  —  Recovery.  —  Eliza  N  --  ,  aged  eighteen,  had  a  discharge  of 
pus  from  the  right  ear  for  two  months.  The  discharge  suddenly  ceased,  and  the 
patient  was  attacked  with  severe  pain  and  swelling  over  the  mastoid,  which  grew 
worse  and  worse  for  several  days,  and  caused  her  to  visit  the  hospital.  Dr. 
Roosa  diagnosticated  mastoid  periostitis,  and  at  once  (May  10,  1869)  made  a  free 
incision  down  to  the  bone.  No  pus  was  found,  but  there  was  free  hemorrhage, 
which  was  encouraged  by  the  use  of  warm  water.  The  membrana  tympani  was 
found  to  be  removed  by  suppuration,  but  there  was  a  slight  discharge  from  the 
canal.  A  tent  was  placed  in  the  wound  and  a  poultice  applied  over  it. 

May  llth.  —  Patient  has  had  no  pain  acd  has  slept  well.  The  tent  was  re- 
applied  and  the  poultice  continued. 

May  16th.  —  The  swelling  of  the  mastoid  is  gone.  There  has  been  at  no  time 
a  discharge  of  pus  from  the  incision,  but  there  was  a  copious  one  from  the 
meatus.  The  patient  was  very  pale  when  first  seen,  but  the  administration  of 
iron  and  the  cessation  of  pain  have  restored  the  normal  condition.  She  has  not 
since  returned  to  the  hospital. 


Chronic  Suppurative  Otitis  Media  —  Mastoid  Periostitis  —  Incision  — 
Recovery.  —  William  G  -  ,  aged  thirty,  came  to  the  Manhattan  Eye  and  Ear 
Hospital,  June  13,  1870.  In  December,  1869,  he  first  experienced  a  sharp  pain 
in  the  left  ear,  which  was  most  severe  at  night.  This  pain  continued  for  two 
months,  at  the  end  of  which  time  a  discharge  occurred  from  the  ear,  which  has 
continued  more  or  less  until  now.  Two  months  later  the  mastoid  process  became 
swelled  and  tender,  and  it  was  opened  and  poulticed  by  a  physician.  A  great 
quantity  of  pus,  as  the  patient  says,  was  discharged,  and  the  pain,  which  had 
been  severe,  was  relieved.  About  four  weeks  after  this  the  pain  in  the  ear  again 
occurred,  and  the  patient  presented  himself  at  the  hospital.  He  presented  the 
appearance  of  a  great  sufferer  ;  he  was  pale  and  haggard  ;  his  hands  were  tremu- 
lous, and  his  countenance  was  anxious.  He  complained  of  great  pain,  referred 
to  the  depth  of  the  ear  and  to  the  head.  The  mastoid  process  was  red  and  hot, 
but  not  swelled  or  tender.  The  auditory  canal  was  exceedingly  sensitive.  The 
membrana  tympani  had  been  removed  by  suppuration,  and  there  was  a  thin 
coating  of  pus  on  the  floor  of  the  cavity  of  the  tympanum.  Air  was  forced  into 
the  middle  ear  by  Politzer's  method,  and  leeches  were  applied  to  the  tragus  and 
mastoid.  On  the  next  day  warm  water  was  freqitently  instilled. 

June  14th.  —  The  pain  in  the  ear  has  decreased,  but  there  is  more  redness  of 
the  mastoid.  Leeches,  to  be  followed  by  a  poultice  were  ordered.  I  did  not 
see  the  patient  after  his  second  visit,  in  consequence  of  my  absence  from  town, 
until  the  20th,  when  I  found  fluctuation  in  front  of  the  meatus,  as  well  as  great 
tenderness  over  the  mastoid,  with  an  increase  of  the  constitutional  symptoms. 
The  patient  was  then  admitted  as  an  in-patient,  and  having  given  him  a  dose  of 
whiskey  on  account  of  his  very  shattered  condition,  I  proceeded  to  make  free 
incisions  down  to  the  bone  in  front  of  and  behind  the  ear.  The  bone  was  not 
denuded  or  roughened.  A  tent  was  inserted  and  a  poultice,  the  latter  to  be 
renewed  every  three  hours.  The  patient  slept  well  that  night  for  the  first  time 
in  some  weeks,  taking  a  dose  of  fifteen  grains  of  hydrate  of  chloral. 


504  MASTOID    PERIOSTITIS— CASES. 

June  28th. — The  patient  has  since  been  free  from  pain.  The  incisions  have 
nearly  healed.  There  is  a  slight  discharge  of  pus  from  the  auditory  canal.  He 
hears  a  watch  when  it  is  laid  upon  the  ear.  His  general  condition  is  now  very 
good,  and  he  is  discharged  at  his  own  request. 

It  is  somewhat  remarkable  that  this  patient  experienced  so 
many  painful  symptoms  of  mastoid  disease  for  so  long  a  time, 
and  yet  escaped  without  disease  of  the  bone.  His  affection  was 
never  more  than  a  disease  of  the  lining  membrane,  with  some 
periostitis,  while  in  a  case  hereafter  to  be  detailed,  of  much  less 
severity,  death  of  the  bone  occurred,  and  meningitis,  with  a 
fatal  result,  supervened.  I  now  think  that  a  free  incision  should 
have  been  made  over  the  mastoid  when  I  first  saw  the  patient, 
although  there  was  then  only  some  redness  of  the  process  and 
no  tenderness,  the  pain  being  referred  to  the  depth  of  the  ear. 
In  the  light  of  my  present  experience,  in  all  cases  where  there  is 
deep-seated  pain  referred  to  the  tympanum,  which  is  not  at  once, 
that  is  to  say,  in  a  few  hours,  relieved  by  leeching,  poultices, 
and  the  warm  douche,  even  if  the  mastoid  cells  do  not  seem  to 
be  involved,  I  should  consider  myself  as  giving  the  patient  the 
benefit  of  a  doubt  by  such  a  depletion  as  a  free  incision  will  afford. 

CASE  V. —  Chronic  Suppurative  Otitis  Media  of  Years'  Standing — Exacerbation 

— Mastoid  Abscess —Incision — Recovery.— Gracie  B ,  aged  thirteen.  April  25, 

1872, 1  was  summoned  to  Newburgh,  by  Dr.  S.  Ely,  to  see  a  case  in  consultation, 
which  Dr.  Ely  justly  regarded  as  urgent.  The  patient  was  a  healthy  girl,  who 
had  had  a  discharge  from  her  left  ear  for  years,  and  who  for  the  past  few  weeks 
suffered  from  an  exacerbation  of  the  disease,  with  acute  symptoms.  Dr.  Ely 
had  observed  that  the  mastoid  process  had  become  red,  and  swelled,  and  tender 
within  the  last  few  days.  We  found  the  patient  in  bed,  and  evidently  in  great 
suffering,  with  considerable  constitutional  disturbance,  hot  skin,  and  frequent 
pulse.  The  neck  was  very  much  swollen,  as  was  the  whole  integument  of  the 
mastoid.  There  was  a  profuse  discharge  of  pus  from  the  ear.  On  consultation 
it  was  agreed  that  an  opening  down  to  the  periosteum  should  be  made  at  once, 
which  I  proceeded  to  do,  the  patient  being  under  the  influence  of  ether.  The 
opening  was  surprisingly  deep,  so  that  the  knife  passed  through  three-quarters 
of  an  inch  of  tissue  before  the  bone  was  reached.  Pus  escaped  quite  freely. 
The  wound  and  the  ear  were  syringed  with  lukewarm  water,  and  an  examination 
made  for  a  fistula,  but  none  was  found.  The  bone  was  denuded  of  periosteum. 
The  membrana  tympani  had  been  long  since  removed  by  suppuration.  The  pa- 
tient had  a  fair  night,  sleeping  without  an  anodyne,  and  rapidly  recovered  after 
the  opening  had  been  made.  A  poultice  was  applied  for  a  short  time,  and  then 
the  opening  was  allowed  to  heal.  The  ear  was  treated  in  the  usual  manner  in 
cases  of  chronic  suppuration. 

June  19th. — The  patient  came  to  town  to  visit  me.  On  examination,  the 
membrana  tympani  was  found  to  be  removed  by  ulceration,  and  a  small  amount 
of  pus  lay  in  the  tympanic  cavity.  The  cicatrix  on  the  mastoid  is  one  inch  long 
and  one-half  inch  from  the  auricle.  The  patient  states  that  the  wound  healed 
in  about  one  week  after  it  was  made. 


CAUIES   AND   ABSCESS   OF    MASTOID.  505 


CARIES  AND  ABSCESS  OF  THE  MASTOID. 

Caries  and  abscess  of  the  mastoid  result  from  an  extension 
of  the  inflammatory  process  that  has  been  described  under  the 
head  of  periostitis.  The  inflammatory  process  advances  to  sup- 
puration. Sometimes,  and  perhaps  in  the  greater  number  of 
cases,  the  suppuration  is  not  extensive  and  finds  an  outlet  in  a 
narrow  fistula.  This  form  is,  of  course,  more  dangerous  than 
mere  periostitis  ;  and  yet  cases  of  caries  and  necrosis  are  some- 
times relieved  at  the  cost  of  much  unnecessary  suffering  to 
the  patient,  by  Nature's  slow  process  of  casting  out  diseased 
bone. 

An  argument  for  temporizing  with  an  undoubted  case  of 
suppuration  within  the  mastoid  cells,  has  sometimes  been  de- 
duced from  this  tedious  manner  in  which  Nature  sometimes 
relieves  a  case  without  inducing  a  fatal  result.  But  every  sur- 
geon should  certainly  endeavor  to  spare  his  patient  the  discom- 
fort and  danger  of  protracted  suppuration,*by  carrying  out  the 
rules  of  his  art,  which  demand  an  early,  free,  and  deep  incision 
whenever  pus  is  to  be  found. 

After  the  detailed  account  that  has  been  given  of  the  symp- 
toms of  mastoid  periostitis,  it  is  perhaps  unnecessary  to  dwell 
at  length  upon  the  clinical  features  of  caries  and  abscess.  It  is, 
moreover,  oftentimes  impossible  to  draw  the  line  between  a  case 
of  periostitis  and  one  of  caries. 

In  many  cases  the  symptoms  of  caries  of  the  mastoid  do  not 
differ  essentially  from  those  of  mastoid  periostitis.  There  is 
the  same  redness,  tenderness,  and  swelling  of  the  process,  at- 
tended by  deeply  seated  and  intense  pain.  In  others,  how- 
ever, the  redness,  tenderness,  and  swelling  are  entirely  absent, 
while  the  pain  referred  to  the  depth  of  the  ear  will  be  the  only 
marked  symptom.  This  pain  is  not  relieved  by  leeches,  and 
anodynes  .will  only  veil  the  symptoms  for  a  brief  period.  Usu- 
ally, however,  even  in  the  insidious  cases,  tenderness  will  be 
shown  upon  firm  pressure  on  the  part.  Yet  the  surgeon  may 
cut  down  upon  a  bone  to  find  it  diseased,  when  he  had  not  been 
previously  able  to  positively  diagnosticate  this  state  of  things. 
It  may  be  said,  however,  in  general  terms,  that  any  deep-seated 
pain  referred  to  the  mastoid  or  its  region,  occurring  in  the 
course  of  an  inflammation  of  the  ear,  should  be  looked  upon 
with  suspicion,  even  if  there  be  no  redness,  tenderness,  or  swell- 
ing of  the  process  itself. 

The  auditory  canal  is  often  involved  in  cases  of.  caries  of  the 
mastoid.  A  fistulous  opening  is  sometimes  found  leading  from 


TREPHINING   THE   MASTOID. 

this  part  into  the  mastoid  cells,  in  which  case  granulations  are 
usually  found  in  the  canal.  The  presence  of  granulations  in  the 
canal  should  lead  us  to  examine  the  part  very  carefully  to  see 
if  a  fistula  may  not  be  found.  In  certain  cases  it  may  be  easier 
to  remove  dead  bone  through  the  external  meatus.  A  clinical 
fact  of  some  importance  in  the  diagnosis  of  mastoid  disease  is 
the  one  that  the  chronic  or  acute  suppurative  process  in  the 
middle  ear  is  often  very  much  less  violent,  or  entirely  checked, 
at  the  time  of  the  outbreak  of  the  periostitis.  This  fact  applies 
to  both  forms  of  the  disease.  Yet  it  is  a  mistake  to  suppose 
that  mastoid  periostitis,  or  caries,  may  not  occur  while  a  free 
discharge  of  pus  is  taking  place  from  the  jar. 

Treatment. — The  first  step  in  the  treatment  of  a  case  of  sup- 
posed caries  of  the  mastoid,  is  to  divide  the  tissues  over  the 
process  down  to  the  bone,  as  was  recommended  for  cases  of 
mastoid  periostitis.  If  a  fistula  be  found,  it  will  be  simply  nec- 
essary to  enlarge  this,  so  as  to  give  a  free  exit  to  the  pus.  This 
enlargement  is  besf  made  by  a  drill  worked  cautiously  in  the 
track  of  the  fistula.  A  good  funnel-shaped  external  opening 
should  be  left,  so  that  the  pus  may  freely  escape  when  it  reaches 
the  surface,  and  not  burrow  beneath  the  tissues,  but  chiselling 
is  unnecessary  and  meddlesome  surgery.  If  there  be  no  fistula, 
an  opening  should  be  made  into  the  cells,  into  the  mastoid  an- 
trum  preferably,  by  a  drill  or  a  small  trephine.  Here  those 
who  prefer  the  chisel  may  use  it,  but  I  like  the  other  instruments 
much  better,  because  the  scar  they  leave  is  insignificant.  Before 
opening  the  bone,  the  periosteum  should  be  stripped  off,  so  as  to 
leave  a  good  field  for  the  operation.  The  instruments  should 
be  usually  entered  on  the  boss  of  the  mastoid,  which  is  usually 
just  on  a  line  with  the  meatus,  and  worked  cautiously  downward 
and  inward.  It  is  impossible  to  say  in  advance  to  what  distance 
one  must  go,  for  this  varies. 

Schwartze  says,  "  Never  go  deeper  than  25  mm."  Buck  says, 
"  It  is  better,  I  believe,  to  place  the  extreme  limit  of  depth  at 
20  mm.,  or  about  three-fourths  of  an  inch."  ' 

By  reference  to  the  anatomy  of  the  mastoid  process  it  will 
be  seen  that  the  thickness  of  the  outer  layer  of  bone  varies 
somewhat  in  different  cases.  The  operation  should  go  on  very 
slowly,  frequent  pauses  being  made  to  see  how  deep  the  instru- 
ment has  gone.  It  is  impossible  to  say  in  a  given  case  at 
what  depth  we  shall  reach  the  cells,  or  free  spaces,  and  thus 
make  an  outlet  for  the  pus.  Dr.  Agnew  was  obliged  to  go  to  the 
depth  of  five-eighths  of  an  inch  in  one  of  his  cases,  and  then 

1  Treatise  on  the  Ear,  p.  369. 


TREPHINING  THE   MASTOID. 


507 


FIG.  107.— Schwartze's  Chisels  for 
Opening  the  Mastoid. 


found  only  sclerosed  bone.  Dr.  D.  C.  Ambrose,  of  this  city,  re- 
moved a  piece  one  inch  long  from  the  mastoid  process  of  a 
young  woman  of  twenty  years  of  age.  The  cell-structure  will 
ordinarily  be  found  at  a  depth  of  from  one-sixth  to  one-fourth  of 
an  inch.  In  infants  the  outer  shell  of  bone  is  so  thin  that  true 
trephining  will  probably  never  be  required  ;  but  any  firm  in- 
strument will  make  the  required  opening.  In  case  of  an  emer- 
gency, a  surgeon  has  been  known  to  use  a  common  gimlet  to 
open  the  mastoid  process.  The  lat- 
eral sinus  will  always  be  avoided  by 
keeping  the  instrument  as  directed 
above.  In  extremely  rare  cases  the 
position  of  the  sinus  is  abnormal  and  it 
will  be  impossible  to  avoid  it.  In  case 
it  is  opened  or  great  bleeding  occurs 
from  the  mastoid  veins,  the  opening 
should  be  plugged  with  oakum  and  a 
compress  applied.  Cases  have  done 
well  where  the  sinus  has  been  opened, 
and  septicaemia  has  resulted.1 

The  after-treatment  is  the  same  as 

that  of  an  operation  for  necrosis  in  other  bones.  The  wound 
should  be  dressed  from  the  bottom  with  oakum  or  iodoform 
gauze,  and  not  allowed  to  heal  too  rapidly.  The  patient  should 
be  kept  free  from  all  noise  and  excitement,  and  very  carefully 
watched  until  the  fistula  has  healed,  which  may  be  for  months. 
I  think  a  long  tent  made  of  old  and  thin  cotton-cloth,  much 
better  than  the  silver,  or  rubber  drainage-tubes.  The  fistulous 
opening  should  be  dressed  at  least  once  a  day.  Of  late,  in- 
stead of  a  cotton  or  linen  tent,  on  the  suggestion  of  one  of  my 
staff,  Dr.  Frank  N.  Lewis,  I  have  used  a  drainage-tube  made 
of  a  quill  with  more  satisfaction  than  any  other.  Dr.  Wilson's 
trephine  for  use  on  the  mastoid  is  ingenious  and  safe.  By  it  the 
distance  to  which  we  go  may  be  easily  and  exactly  regulated. 

In  some  cases — I  have  one  such  under  observation,  which 
was  operated  upon  by  Dr.  E.  T.  Ely — the  fistula  cicatrizes 
throughout  its  course,  but  never  closes.  I  have  also  seen  a 
case,  kindly  sent  me  by  Professor  Sayre,  where  an  opening 
made  by  a  bullet  also  left  a  permanent  opening  without  suppu- 
ration or  other  inflammation.  The  patient,  who  received  the 
wound  in  the  late  civil  war,  wore  a  cover  to  the  opening. 

I  have  seen  59  cases  of  affections  of  the  mastoid  process, 
in  5,797  cases  of  aural  disease  occurring  in  private  practice. 
Occasionally  I  have  omitted  to  record  one  which  I  have  seen 

1  In  other  cases  opening  the  sinus  has  been  followed  by  no  evil  consequences. 


508  CARIES   AND   ABSCESS   OF   MASTOID — CASES. 

in  consultation,  but  there  are  not  many  such,  so  that  the  record 
is  tolerably  exact. 

Thirty -three  cases  occurred  in  my  practice  at  the  Manhattan 
Eye  and  Ear  Hospital  in  eighteen  years.  The  total  number  of 
cases  that  have  been  diagnosticated  as  affections  of  the  mas- 
toid,  in  all  the  aural  departments  of  this  institution  for  eigh- 
teen years  is  110. 

Here  there  is  a  source  of  error,  for  some  cases  that  entered 
the  hospital,  and  were  diagnosticated  as  simple  catarrh  or  sup- 
puration finally  became  cases  of  mastoid  disease.  Besides  this, 
many  made  but  a  few  visits  and  never  returned,  so  that  we 
knew  nothing  in  many  instances  of  the  ultimate  results.  At 
the  close  of  the  paper  will  be  found  statistical  tables  in  more  or 
less  detail  of  the  total  number  of  cases. 

CASES.    ' 

A  summary  of  all  the  cases  here  reported  shows  as  follows  : 
Summary  of  Cases  in  Private  Practice. 

Number  of  cases  treated,  males 33 

Number  of  cases  treated,  females 26 

59 

Result. 

Died 9 

Cured 36 

Believed 10 

Unknown  4 

59 

The  disease  of  the  mastoid  occurred  in  the  following-named 
affections  : 

Acute  catarrhal  inflammation  of  the  middle  ear 11 

Acute  suppuration  of  the  middle  ear 25 

Chronic  suppuration  of  the  middle  ear 18 

Primary  mastoid  periostitis 1 

Inflammation  of  the  external  auditory  canal 2 

Exostosis  of  the  masfcoid 1 

Neuralgia  of  the  middle  ear 1 

59 

Operations. 

Wilde's  incision  m^de  with  evacuation  of  pus 9 

Wilde's  incision  without  pus 11 

Mastoid  opened  by  enlarging  fistula 10 

Opened  without  finding  fistula 4 

Opened  through  external  auditoiy  canal 2 

42 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  509 

Summary  of  Cases  Treated  in  the  Author's  Clinique  at  the  Manhattan  Eye  and 

Ear  Hospital. 
Number  of  cases  treated . . 33 

Result. 

Cured 14 

Relieved 5 

Died 1 

Unknown 14 

33 

Disease. 

Acute  catarrh  of  the  middle  ear 2 

Sub-acute  catarrh  of  the  middle  ear 1 

Acute  suppuration,  middle  ear 8 

Acute  suppuration  of  the  middle  ear,  with  rnastoid  fistula 1 

Sub-acute  suppuration  of  the  middle  ear 1 

•    Chronic  suppuration,  middle  ear 11 

Chronic  suppuration  of  the  middle  ear,  with  mastoid  fistula ...  4 

Chronic  suppuration,  middle  ear,  with  polypus 1 

Chronic  catarrh  of  the  middle  ear 1 

Primary  inflammation  of  the  mastoid 2 

Impacted  cerumen  with  mastoid  periostitis 1 

33 

Operations. 

Wilde's  incision 7 

Wilde's  incision,  pus  evacuated 5 

Opening  mastoid  with  a  drill 14 

Treated  without  operation 7 

33 

Cases  in  which  death  occurred.  There  were  ten  of  such  cases 
in  private  practice  and  "one  in  the  hospital  cases.  One  of  the 
deaths  was  probably  not  induced  by  the  aural  disease ;  but  the 
others  are  undoubtedly  to  be  classified  in  this  way  : 

CASE  "L—Suppurative  Inflammation  of  the  Middle  Ear  soon  after  Birth — Mas- 
toid Periostitis — Incisions — Death. — Boy,  aged  three  months,  seen  in  consultation 
with  Dr.  M.  W.  Williams.  There  was  an  abundant  discharge  of  pus  from  the 
tympanum.  Considerable  oedema  of  the  mastoid,  and  evidences  of  meningitis. 
Dr.  Williams  had  incised  the  tissues  down  to  the  bone  before  I  saw  the  patient. 
I  repeated  this  incision  a  few  days  after.  No  pus  was  found.  Inasmuch  as 
there  was  free  drainage  from  the  tympanum,  no  further  operation  was  performed. 
The  patient  died  in  a  few  days  afterward. 

CASE  II. — Suppuration  of  the  Middle  Ear  fw  Six  Years — Death. — Female, 
aged  fifty.  Four  years  ago  she  had  an  attack  of  severe  pain  and  swelling  in  the 
right  ear  from  which  she  recovered,  but  a  discharge  remained.  One  year  ago 
she  had  acute  inflammation  of  the  mastoid  process.  The  integument  and  peri- 
osteum were  incised,  pus  discharged  for  two  months  and  then  ceased.  Two 
weeks  ago  the  inflammation  recurred  in  the  same  part.  There  was  intense  pain 


510  CARIES   AND   ABSCESS   OF   MASTOID — CASES. 

in  the  ear,  and  an  offensive  discharge  from  it;  the  latter  continued.     H.  D.,  R., 

£o>  -k'j  sV 

The  patient  has  been  living  in  a  malarial  district,  and  has  taken  largely  of 
quinine. 

The  left  auditory  canal  is  narrowed  and  crooked,  and  filled  with  pus.  The 
drum-head  is  nearly  gone,  and  there  is  caries  of  the  tympanum,  the  mastoid 
cells,  and  posterior  wall  of  the  auditory  canal.  Dr.  E.  T.  Ely  saw  the  patient 
for  me  at  first,  and  advised  the  application  of  six  leeches  and  the  hot  douche 
every  three  hours.  In  a  few  days  the  patient  was  much  better,  the  mastoid  was 
not  tender,  but  there  was  intense  pain  in  the  head  and  constant  vertigo.  The 
bones  of  the  tympanum  were  gone,  and  the  foramen  ovale  probably  opened.  I 
learned  afterward  this  patient  died  very  soon  after  Dr.  Ely  and  I  saw  her,  which 
we  did  but  a  few  times,  when  we  were  dismissed. 

CASE  III. — Acute  Suppuration  of  the  Middle  Ear — Mastoid  Periostitis — Menin- 
gitis— Death. — This  case  has  already  been  published  in  full  (Medical  Record,  July 
6,  1877).  It  is  simply  necessary  to  say  here  the  patient  died  of  meningitis, 
from  acute  suppuration  of  the  middle  ear,  in  twenty- eight  days  from  the  first 
attack  of  aural  inflammation.  Wilde's  incision  was  made,  but  no  disease  of 
the  bone  was  found,  and  the  post-mortem  examination  showed  that  such  an 
opening  would  have  been  in  vain. 

CASE  IV. — Chronic  Suppuration  of  Right  Middle  Ear — Mastoid  Swelling — Ab- 
scess—  Opened  with  Drill — Died  about  Three  Months  after  from  Meningitis. — Male, 
aged  twenty.  Under  the  writer's  observation  for  about  fourteen  days. 

The  patient  has  had  a  discharge  from  his  right  eye  ever  since  infancy.  The 
drum-head  of  that  side  is  gone,  and  there  is  a  very  free  discharge  of  pus  from 
it.  The  whole  surface  of  the  mastoid  is  swelled  and  excessively  tender.  A  free 
incision  was  made  down  to  the  bone  and  a  fistula  was  found  leading  into  the 
tympanum.  This  was  enlarged  and  a  tent  introduced  and  poultices  applied. 
The  patient  remained  under  daily  observation  in  New  York  for  eight  days,  when 
he  returned  to  his  home  to  be  under  the  care  of  his  family  physician.  I  saw 
him  once  or  twice  afterward.  He  did  well  until  July  or  August,  when  he  died 
suddenly  at  a  watering-place,  as  I  was  informed,  from  meningitis. 

CASE  V. — Bronchitis — Acute  Suppuration  of  the  Right  Middle  Ear — Chills  Sim- 
ulating Ague  and  Fever — Mastoid  Abscess  Opened  with  a  Drill — Death  Four  Days 

after. — D.  I ,  aged  sixty -nine,  on  April  6,  1886,  was  sent  to  my  office  by  Dr. 

M.  H.  Williams  with  the  following  history  :  He  had  acute  bronchitis  three  and  a 
half  months  before,  which  in  about  two  weeks  was  followed  by  earache.  This 
ceased  when  the  ear  began  to  discharge,  but  the  suppuration  has  continued  ever 
since.  The  ear  was  carefully  cleansed  with  warm  water,  and  an  astringent  in- 
stilled, and  the  ear  was  inflated  by  Politzer's  method.  There  was  occasionally 
some  bleeding  from  the  tympanum  on  cleansing. 

The  patient  has  excellent  care  under  good  hygienic  conditions.  To-day  the 
patient  has  no  pain,  slight  tinnitus  occurred,  but  no  other  aural  symptom. 

H.  D.,  jiy ;  L.,  ^J.  Bone-conduction  better  than  aerial  on  that  side.  When  the 
tuning-fork  is  placed  on  the  sound  mastoid  it  appears  to  be  heard  on  the  dis- 
eased side.  This  is  a  symptom  which,  as  is  well  known,  is  quite  often  seen,  and 
when  it  is,  always,  in  my  opinion,  indicates  advanced  disease  of  the  tympanum  and 
cells,  not  necessarily  suppuration  however,  with  greatly  increased  resonance  of 


C  A  HIES   AND   ABSCESS   OF   MASTOID — CASES.  511 

these  parts.  The  nares  are  in  a  catarrhal  condition.  The  posterior  half  of  the 
drum-head  is  swept  away,  the  remainder  is  red  ;  a  rather  thick  discharge  from 
the  tympanum.  No  tenderness,  pain,  swelling,  or  redness  of  the  mastoid. 
Simple  cleansing  was  advised.  Nearly  a  month  after,  on  May  4,  1886,  I  again 
saw  the  patient  at  his  house  and  got  the  following  history  from  Dr.  Williams. 
The  patient  was  doing  fairly  well  until  April  31st,  when  he  had  a  chill  followed 
by  fever.  He  has  had  a  chill  nearly  every  day  since.  The  mastoid  is  slightly 
tender  at  the  apex,  there  is  no  oedema  and  no  pain,  but  that  side  of  his  head 
feels  uncomfortable.  The  next  day  the  uncomfortable  sensation  had  increased, 
and  the  usual  incision  was  made  through  the  integument  and  the  bone  opened 
with  a  drill.  The  depth  reached  was  about  half  an  inch,  when  pus  flowed  out 
in  considerable  quantity.  A  tent  was  inserted  and  a  poultice  applied.  In  the 
evening  the  patient  was  very  comfortable.  Temperature,  98£°.  Pulse,  78. 

May  6th. — The  patient  had  a  chill  lasting  half  an  hour,  and  his  temperature 
went  up  to  104^°.  Two  days  after,  he  died,  herniplegia  having  occurred. 

CASE  VI. — Chronic  Suppuration  of  Long  Standing — Great  Pain  in  the  Head — 
Delirium — Opening  of  the  Mastoid — Death. — Male,  aged  twenty-five.  This  pa- 
tient was  seen  twice  in  consultation.  The  history  was  that  he  had  had  a  sup- 
purating ear  on  the  right  side  for  many  years,  and  occasionally  he  has  been  laid 
up  with  earache.  He  has  been  sick  now  for  two  weeks.  Pulse,  90.  Tempera- 
ture. 104°.  The  tympanum  is  suppurating  moderately.  The  apex  of  the  mas- 
toid process  is  tender  upon  firm  pressure,  but  there  is  no  pain  except  in  the 
head,  and  that  is  not  severe.  The  previous  treatment  has  been  the  use  of 
quinine  and  the  application  of  leeches. 

The  diagnosis  was  meningeal  hypersemia,  from  acute  suppuration  supervening 
upon  chronic  suppuration.  Four  leeches  were  advised,  and  poultices  around 
the  ear.  I  heard  nothing  more  of  the  patient  until  fifteen  days  later.  I  was 
again  sent  for.  The  physician  in  attendance  concluded  that  the  high  tempera- 
ture was  due  to  malarial  poisoning,  and  has  given  large  doses  of  quinine.  Hie 
also  made  an  incision  through  the  periosteum  of  the  mastoid  process,  which  has 
nearly  healed.  The  patient  is-  now  delirious,  flinches  when  pressure  is  made 
upon  the  mastoid.  The  mastoid  was  opened  with  a  small  drill  into  the  cells. 
No  pus  was  found.  The  blood  was  exceedingly  dark,  but  there  was  no  serious 
hemorrhage.  The  patien.t  died  three  hours  later.  At  my  first  visit  to  this  patient 
I  thought,  and  expressed  my  opinion,  that  the  pus  that  formed  on  this  case  was 
probably  inaccessible,  for  I  supposed  that  the  apex  of  the  petrous  bone  or  the 
roof  of  the  tympanum  rather  than  the  mastoid  was  the  principal  seat  of  the 
disease.  I  did  not  concur  in  the  use  of  the  quinine,  and  never  supposed  that 
there  was  any  determining  malarial  element  in  the  case.  When  I  got  consent 
to  opening  the  mastoid  I  did  not  hesitate,  however,  for  I  think  many  lives  have 
been  lost  because  concealed  pus  has  not  been  evacuated  in  such  cases.  With  my 
present  convictions,  in  dangerous  suppuration  of  the  tympanum  I  shall  always 
lean  toward  opening  the  mastoid,  believing  as  I  do  that  such  an  opening  secures 
the  best  drainage  possible  for  the  tympanum.  Much  as  I  deplore  unsuccessful 
cases,  I  shall  never  hesitate  to  perform  what  I  believe  to  be  an  operation  almost 
without  danger — in  a  doubtful  and  dangerous  case.  In  a  case  to  be  described 
hereafter,  occurring  in  the  Manhattan  Eye  and  Ear  Hospital,  in  my  service,  and 
operated  upon  by  Dr.  Emerson  with  my  assistance,  a  case  almost  desperate,  life 
was,  I  think,  saved  by  a  timely  trephining,  although  no  pus  was  found. 


512  CARIES   AND    ABSCESS   OF    MASTOID— CASES. 

CASE  VII. — Chronic  Suppuration  of  the  Middle  Ear  since  Infancy — Acute 
Otitis — Spontaneous  Opening  of  the  Mastoid  Process — Enlargement  of  the  Opening 

— Phthisis  Pulmonalis — Death. — C.  P ,  aged  twenty-one.  It  is  doubtful  if 

death  in  the  following  case  was  due  to  the  aural  disease.  Certainly  it  was  not  a 
result  of  any  operative  interference  or  other  treatment.  About  three  months 
after  he  was  seen  by  Dr.  Ely  and  myself,  in  consultation  with  Dr.  F.  A.  Utter,  he 
died  of  phthisis  pulmonalis.  The  history  stated  that  the  patient  had  had  a  dis- 
charge from  the  left  ear  for  a  long  time  from  early  youth.  Four  weeks  ago  he 
had  violent  pain  in  the  ear,  extending  to  the  side  of  the  head  and  neck,  a  swell- 
ing in  the  mastoid  opened  spontaneously  a  few  days  since.  The  patient  is  veiy 
pale  and  weak.  Temperature,  98|°.  Pulse,  120.  The  entrance  to  the  auditory 
canal  is  obstructed  by  granulations  from  the  posterior  wall.  There  is  a  small 
sinus  'below  the  tip  of  the  mastoid.  Rough  bone  is  felt  at  the  bottom.  He  has 
no  pain  now.  The  opening  was  enlarged  and  a  tent  inserted.  The  tissues  are 
very  boggy. 

The  patient  got  better  so  as  to  be  up  and  about,  a  free  opening  into  the  mas- 
toid cells  was  maintained,  but  the  patient  died  in  three  months  after. 

CASE  VIII. — Chronic  Suppuration  of  the  Middle  Ear — Extensive  Necrosis  of 
tlie  Mastoid  Process — Epithelial  Tumor  extending  into  the  Cranial  Cavity — No  Ex- 
ternal Swelling — Death. — In  consultation  with  Dr.  Mathewson.  This  case  has 
been  fully  reported  elsewhere  ("  Transactions  of  the  American  Otological  Society, 
1878  ").  This  patient  was  a  young  married  woman,  in  good  general  health,  who 
had  had  a  purulent  discharge  from  the  left  ear  for  ten  years.  When  first  seen 
by  Dr.  Mathewson,  and  subsequently  by  myself,  she  was  suffering  'pain  from  the 
ear.  There  were  fungous  granulations  springing  out  of  the  tympanum.  There 
was  no  swelling;  tenderness,  or  pain  in  the  mastoid. 

Four  months  after  first  coming  to  Dr.  Mathewson  he  opened  the  mastoid, 
which  was  still  not  swollen  or  tender,  and  very  extensive  necrosis  was  found. 
Two  months  after  I  again  saw  the  patient.  There  was  considerable  pain  in  the 
head  and  ear.  The  mastoid  opening  was  nearly  closed.  The  canal  was  ob- 
structed by  granulations.  The  next  day  Dr.  Mathewson  removed  many  pieces 
of  dead  bone  ;  a  wide  opening  remained  down  to  the  dura  mater.  The  patient 
died  two  months  later,  eight  months  after  she  came  under  Dr.  Mathewson's 
care.  A  full  account  of  the  post-mortem  examination  of  this  interesting  case 
appears  in  the  report.  From  this  it  appears  that  the  growth  had  its  origin  in  the 
tympanum,  and  that  the  mastoid  was  affected  only  at  a  late  stage. 

CASE  IX. — Acute  Suppuration  of  the  Middle  Ear — Redness  and  Swelling  of  the 
Mastoid — Bronchitis — Fistula  of  Mastoid  Enlarged— Death. — Male,  aged  three. 
Seen  in  consultation  with  Dr.  Emerson.  The  patient  has  had  a  discharge  from 
his  left  ear  for  the  past  six  weeks.  For  two  weeks  there  has  been  redness  of  the 
mastoid  process  of  that  side,  and  slight  swelling.  There  is  no  fluctuation  nor 
tenderness  on  pressure.  The  auditory  canal  is  much  swollen.  Dr.  Emerson 
advised  the  hot  douche  and  poultices,  and  nine  days  after  he  was  called  by  Dr. 
Harrison  to  see  the  patient  again.  He  learned  that  the  little  patient  had  had 
pain  for  two  days.  The  swelling  of  the  mastoid  had  nearly  disappeared.  There 
was  no  redness,  but  there  was  pain  on  pressure.  The  next  day  I  saw  the  pa- 
tient with  Dr.  Emerson.  He  made  a  Wilde's  incision,  found  a  fistula  in  the 
bone,  which  he  enlarged.  The  patient  slept  well  the  night  after  this,  but  he 
died  three  days  after  in  a  convulsion. 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  513 

DEATHS  PROM  CASES  OCCURRING  IN  HOSPITAL  PRACTICE. 

The  only  death  I  have  seen  from  aural  disease  in  my  service 
at  the  Manhattan  Eye  and  Ear  Hospital  for  eighteen  years  was 
that  of  a  patient  under  the  care  of  Dr.  Emerson  and  myself. 

CASE  X. — Sub-acute  Suppuration  of  the  Middle  Ear — Mastoid  Tenderness — Open- 
ing of  Bone — No  Fistula  or  Pus  Found — Death  in  Forty-two  Days. — Male,  laborer, 
aged  thirty-seven,  was  treated  as  an  out-patient  for  two  weeks  before  he  entered 
the  hospital.  He  said  he  had  a  painful  ear  for  three  weeks  before  this.  The 
warm  douche  and  leeches  have  been  used.  On  admission  to  the  hospital,  on 
June  9,  1877,  he  complains  of  dizziness  and  pain.  He  was  found  to  have  a 
sub-acute  suppurative  process  in  the  middle  ear.  He  apparently  improved 
under  local  treatment  for  three  days,  when  he  had  a  chill  and  his  temperature 
went  up  to  103°. 

The  mastoid  was  opened  by  Dr.  Emerson,  assisted  by  myself,  on  that  day. 
The  bone  was  drilled  to  the  depth  of  one  inch.  No  pus  and  no  fistula  were 
found,  and  there  was  no  softening  of  the  external  plate.  The  temperature  fell 
to  100°  that  evening,  but  it  rose  the  next  day  to  103°.  The  patient  was  chilly, 
nauseated.  He  continued  to  suffer  from  nausea  for  several  days  ;  his  tempera- 
ture ranged  from  101°  to  103°,  and  on  June  21st  it  arose  to  105°.  On  this  day 
his  pulse  was  increased  to  80  for  the  first  time.  It  had  before  ranged  from 
72  to  76.  He  now  has  delirium  at  times.  He  is  given  quinine  and  bromide  of 
potassium.  On  the  22d  he  had  a  chill  lasting  an  hour.  The  discharge  of  pus 
from  the  ear  is  scanty.  He  continued  in  about  this  way  for  three  days,  when  his 
temperature  fell  to  98^°,  and  the  next  day  to  97°.  He  continued  to  have  chills, 
and  on  June  28th  his  pulse  was  120.  An  examination  of  the  optic  nerve  and 
retina  showed  nothing  abnormal.  The  patient  died  of  septicaemia  on  July  31st, 
nearly  two  months  after  his  admission. 

The  purulent  infection  was  in  the  roof  of  the  tympanum  or 
at  the  apex  of  the  petrous  "bone.  We  were  not  hopeful  of  the  re- 
sults of  opening  the  bone,  but  we  desired  to  obtain  an  outlet  for 
pus,  but  in  this  we  were  not  successful. 

Cases  in  which  a  cure  resulted  after  operation  :   ' 

CASE  XI. — Caries  of  the  Mastoid  from  Chronic  Suppuration  of  the  Middle  Ear — 

Mastoid   Opened   Three    Times— Recovery. — Miss   X ,    aged    twenty-six.     As 

this  case  is  reported  in  my  book  on  the  Ear,  p.  529,  I  will  simply  say  that  the 
patient  was  under  observation  and  treatment  for  some  eight  months.  Although 
the  bone  had  been  opened  twice  before  I  saw  the  case,  once  with  a  chisel,  the 
patient,  who  is  a  teacher,  was  unable  to  do  any  mental  work  on  account  of  pain 
and  dizziness.  After  a  thorough  opening  up  of  the  old  fistula  with  a  drill,  and 
subsequent  persistent  curetting  of  granulations,  the  patient  entirely  recovered ; 
the  drum-head  did  not  heal,  however  ;  she  resumed  her  duties,  which,  ten  years 
later,  she  still  continues  to  perform  without  trouble  from  her  ear. 

To  my  mind,  a  case  of  mastoid  disease  arising  in  the  course 

of  a  chronic  suppuration  always,  or  nearly  always,  involves  a 

tedious  course  varying  from  two  to  six  months  if  cure  results. 

It  is  otherwise  with  the  same  form  of  disease  arising  in  the 

83 


514  CARIES   AND   ABSCESS   OF   MASTOID — CASES. 

course  of  acute  catarrh  and  acute  suppuration.  In  such  cases 
the  recovery  may  be  rapid  and  death  also  may  speedily  result. 
He  who  succeeds  in  curing  cases  where  he  has  opened  the  mas- 
toid  de  novo,  or  enlarged  a  fistula,  must  expect  weeks  of  rather 
dreary  work  -of  keeping  the  opening  free,  by  frequently  curet- 
ting the  granulations,  picking  away  the  minute  fragments  of 
dead  bone,  pushing  in  a  tent,  a  drainage-tube,  or  the  like.  With 
such  patience,  success  will  generally  crown  the  effort. 

I  am  very  unwilling  to  operate  upon  a  case  unless  either  one 
of  my  staff,  or  myself,  or  a  competent  surgeon,  alive  to  the  im- 
portance of  the  prevention- of  retention  of  pus,  have  the  subse- 
quent charge  of  the  case.  The  after-treatment,  I  think,  invokes 
much  more  skill  than  the  operation. 

CASK  XII.  —  Caries  of  Mastoid  of  Nasal  Bone  and  of  Jaw — Removal  of  Pieces  of 
Dead  Bone  from  Various  Parts — Recovery. — Female,  aged  five.  This  case  also 
illustrates  what  has  just  been  said  on  the  subject  of  keeping  up  the  openings  in 
the  bone  until  the  last  of  the  unhealthy  tissue  is  removed. 

The  child  was  apparently  a  healthy  one  of  healthy  parents.  She  was  sent 
to  me  by  the  late  Dr.  Lewis  Fisher,  and  she  was  under  the  care  of  Dr.  Ely  and 
myself  for  more  than  four  years.  A  mastoid  fistula  existed  when  I  first  saw 
her,  when  she  was  three  years  of  age.  Dr.  Abbot,  dentist,  of  this  city,  had  the 
care  of  the  caries  of  the  jaw  ;  she  was  etherized  several  times,  to  keep  open  the 
original  enlargement  of  the  bone  fistula  and  to  remove  granulations  from  the 
tympanum.  Finally  she  recovered,  with  a  neoplastic  non-suppurating  tympa- 
num, and  the  mastoid  fistula  healed. 

Several  cases  have  recovered  without  perforation  of  the  mas- 
toid by  getting  the  patient  in  bed  under  the  charge  of  a  trained 
nurse,  and  the  free  use  of  the  warm  douche,  leeches,  and  poul- 
tices. Most  of  the  patients  who  have  been  thus  relieved  have 
been  of  decided  neurotic  tendencies,  and  although  they  have 
had  great  tenderness  and  pain  in  the  mastoid,  have  probably 
never  had  more  than  periostitis.  No  caries  occurred,  except  in 
some  instances  caries  of  the  wall  of  the  auditory  canal,  when  it 
opens  into  the  mastoid. 

But  I  have  written  upon  this  subject  at  some  length  in  pre- 
ceding pages. 

A  case  which  I  have  lately  seen,  in  consultation  with  Dr.  F. 
W.  Ring,  and  which  we  treated  together  in  the  Manhattan  Eye 
and  Ear  Hospital,  re-illustrates  the  points  I  have  endeavored  to 
make. 

CASE  XIII. — Acute  Suppuration  m  both  Middle  Ears — Red,  Sensitive,  and  Ten- 
der Mastoid — Increase  of  Temperature — No  Operation — Recovery. — Mrs.  G , 

aged  twenty-five.  November  30,  1886.  Five  months  previously  the  patient  suf- 
fered from  acute  suppuration  of  both  middle  ears,  while  in  the  West  Indies. 
The  suppuration  and  pain  have  continued  at  intervals  ever  since- 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  515 

Occasionally  she  is  quite  well.  She  has  been  under  Dr.  Ring's  care  for  more 
than  two  months.  Under  his  treatment  the  right  drum  is  now  healed  ;  R.,  H.  D., 
|.| ;  bone  conduction  better ;  L.,  H.  D.,  ¥Lg  ;  B.  C.,  better.  There  is  pus  in  the  left 
tympanum.  The  mastoid  of  that  side  is  reddish,  painful,  and  tender.  The 
temperature  at  about  11  A.M.  was  102°,  and  had  been  for  a  few  days.  She  was 
anaemic  and  neurotic.  She  lived  in  a  boarding-house  and  had  insufficient  care. 
On  the  advice  of  Dr.  Ring  and  myself  she  was  admitted  to  the  hospital.  She 
was  kept  in  a  quiet  room,  was  fed  with  milk,  chiefly  stimulants,  latterly  cham- 
pagne was  given  pro  re  nata,  massage.  Her  temperature  sank  to  normal  in  a  few 
hours  after  getting  under  hospital  care.  The  right  drum -head  again  broke 
down,  but  finally  healed.  Locally  the  hot  douche  and  poultices  were  used.  She 
was  discharged  cured.  She  went  to  Chicago,  had  a  mild  attack  of  acute  suppura- 
tion without  mastoid  trouble,  from  which  she  completely  recovered  in  twenty 
days. 

One  of  my  cases  at  the  Manhattan  Eye  and  Ear  Hospital, 
one  in  which  I  found  a  fistula  in  the  bone  and  enlarged  it, 
developed  acute  facial  erysipelas.  The  temperature,  without 
the  administration  of  medicine,  fell  in  one  day  from  104°  to  97°. 
The  shock  was  great,  but  the  patient  rallied  and  made  a  good 
recovery.  The  drum-head  healed.  Facial  erysipelas  also  oc- 
curred in  another  case  where  the  operation  of  drilling  the  bone 
was  performed  by  Dr.  F.  Tilden  Brown,  then  one  of  my  assist- 
ants. This  case  may  be  found  in  this  book,  page  524. 

The  following  case,  which  occurred  in  private  practice  in 
consultation  with  Dr.  E.  M.  Pulling,  and  has  a  peculiar  interest 
from  the  fact  that  descending  optic  neuritis  resulting  in  atrophy 
occurred. 

CASE  XIV. — Willie  X ,  a"ged  six.  April  10,  1885.  Has  had  pain  and  dis- 
charge from  his  right  ear  for  some  days.  He  is  in  bed.  Temperature  100£°. 
The  right  membrana  tympani  is  perforate.  There  is  inspissated  pus  in  the 
tympanum.  The  mastoid  process  is  red  and  swelled.  An  incision  was  made 
down  to  the  bone,  about  one  ounce  of  thick  pus  was  evacuated.  The  perios- 
teum was  found  to  be  extensively  diseased,  but  no  fistula  in  the  bone  was  found. 
The  patient  slept  well  that  night  and  recovered.  Case  went  on  well  as  to 
the  ear.  Dr.  Pulling  afterward  made  counter-openings  to  prevent  burrowing, 
but  no  opening  in  the  mastoid  bone  was  ever  made,  and  on  March  2d,  of 
this  year,  I  again  examined  him.  I  found  two  linear  scars  on  the  mastoid,  the 
membrana  tympani  is  sound  and  has  good  light  spot,  and  is  of  good  color. 
H.  D.,  ja  ;  A.  C. ,  better  than  B.  C. 

The  peculiar  interest  in  the  case  is  found  in  Dr.  Pulling's 
account  of  the  subsequent  progress  of  the  case  and  in  the  results 
of  the  ophthalmoscopic  examinations  which  I  made.  Dr.  Pulling 
writes  :  "  After  you  last  saw  Willie  he  had  meningitis,  lasting 
four  to  five  weeks.  He  took  bromides  in  full  doses,  with  aconite 
and  so  forth,  when  the  temperature  rose.  His  condition  gradu- 


516  CARIES   AND   ABSCESS   OF   HASTOID — CASES. 

ally  improved,  and  at  the  end  of  two  months  or  more  from  the 
date  of  your  last  examination  his  health  seemed  quite  well 
established.  About  this  time,  however,  it  was  observed  that  his 
vision  was  becoming  defective.  The  impairment  of  sight  I  as- 
sumed to  be  due  to  constriction  of  the  optic  nerve  from  contrac- 
tion of  the  tissues  about  it." 

The  patient,  March  2,  1887,  has  only  perception  of  light  in  the  right  eye  and 
TSo  on  the  left.  Both  optic  papillae  are  in  a  state  of  white  atrophy.  The  lateral 
vessels  have  all  disappeared  from  the  right  papilla. 

It  is  no  new  observation  to  find  basilar  meningitis  in  the 
course  of  acute  inflammation  of  the  tissues  of  and  adjacent  to 
the  temporal  bone.  Our  attention  has  been  called  by  Kipp, 
Andrews,  and  others  to  the  usefulness  of  ophthalmic  examina- 
tions in  the  course  of  diseases  of  the  mastoid,  but  I  think  it  very 
unusual  for  a  patient  to  recover  from  a  suppurative  inflam- 
mation of  the  tympanum,  with  mastoid  periostitis,  to  become 
blind  from  optic  neuritis  and  subsequent  atrophy. 


CASE  XV. — Scarlet  Fever — Acute  Suppuration  of  the  Right  Middle  Ear — Pain  in 
the  Head — Swelling  and  Redness  of  the  Mastoid — Incision  through  the  Periosteum — 

Fistula  Found  and  Enlarged — Still  under  Treatment. — Miss  W ,  aged  fifteen. 

The  patient  was  attacked  by  scarlet  fever  on  November  3,  1886.  On  the  13th 
she  was  seized  with  a  severe  pain  in  the  head  and  with  pain  in  the  ear.  These 
pains  continued  for  several  days  until  the  membrana  tympani  broke,  when  the 
pain  was  materially  relieved. 

The  pain  in  the  head  continued,  however,  accompanied  by  a  free  purulent 
discharge  from  the  auditory  canal,  until  February  5th — about  three  months.  I 
then  saw  her  for  the  first  time,  and  found  the  patient  anaemic  and  evidently 
suffering.  The  right  membrana  tympani  was  nearly  gone,  and  the  tympanum 
velvety.  The  left  drum-head  was  intact.  No  tenderness  or  redness  of  the  mas- 
toid. The  hot  douche  was  prescribed,  and  the  ear  kept  clean.  Four  days  after 
the  patient  had  severe  pains  through  the  temples  at  the  apex  of  the  mastoid. 
Leeches  were  applied,  and  relief  given  for  two  or  three  days,  but  on  February 
14th  the  pain  reappeared.  There  was  found  to  be  considerable  swelling  and 
redness  of  the  mastoid.  At  5  P.M.  the  temperature  was  101$  °. 

An  incision  was  made,  the  periosteum  removed,  and  a  fistula  found  leading 
from  above  the  middle  of  the  process  into  the  tympanum.  Some  pus  came 
from  this.  This  was  enlarged  with  a  drill.  A  tent  and  poultice  applied.  She 
began  to  improve  the  next  day,  and  her  condition  at  this  writing,  a  little  more 
than  four  weeks  from  the  operation,  is  as  follows :  No  headache,  anaemia  dis- 
appearing, scarcely  any  discharge  from  the  tympanum,  and  a  moderate  sup- 
puration passes  through  a  drainage-tube  inserted  into  the  mouth  of  the  fistula 
in  the  bone.  Temperature  normal.  Patient  goes  out. 

March  31st. — Fistula  in  bone  has  healed.  Membrana  tympani  restored. 
H.  D.,  -&.  Subsequently  the  hearing  became  normal. 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  517 

CASE  XVI. — Chronic  Suppuration  of  the  Middle  Ear — Mastoid  Periostitis — 
Openings  down  to  the  Bone — Enlargement  of  the  Fistula — Patient  still  under  Treat- 
ment.— H.  B ,  aged  sixteen,  was  brought  to  me  March  4,  1887,  by  Dr.  W.  H. 

Cummings,  of  Honesdale,  Pa.,  on  account  of  pain  in  the  head,  dizziness,  and 
occasional  swellings  of  the  mastoid  process. 

The  hearing  distance  on  the  right  side  is  normal.  The  drum-head  is  cica- 
tricial  and  intact.  The  left  mastoid  process  is  depressed,  and  has  a  minute 
opening,  about  which  the  tissues  are  boggy.  A  fine  probe  passed  into  it  can 
with  difficulty  be  made  to  enter  the  bone.  The  auditory  canal  was  half-filled 
with  sanious  pus.  It  was  believed  that  the  tympanum  and  mastoid  were  the 
seat  of  purulent  inflammation,  and  that  they  were  not  well  drained. 

That  day  the  patient  was  etherized  at  the  Post-Graduate  Hospital,  a  free 
incision  was  made  down  to  the  bone,  the  minute  fistula  enlarged  with  a  drill 
and  the  gouge.  The  tissue  of  the  mastoid  was  found  to  be  very  soft,  and  an 
opening  into  the  tympanum,  about  one-fourth  of  an  inch  in  diameter,  was  easily 
made.  A  large  quantity  of  cheesy,  inspissated  pus,  as  well  as  that  of  a  fluid 
quality,  was  evacuated.  The  patient  is  steadily  improving,  has  no  headache  or 
dizziness.  Whether  or  not  he  will  have  a  permanent  fistula  remains  to  be  seen. 
The  mastoid  tissues  have  been  previously  opened  several  times  down  to  the 
bone,  but  not  into  it,  but  for  the  first  time  thorough  drainage  has  been  secured. 

May,  1891.— A  fistula  still  exists  and  is  probably  permanent.  The  patient 
made  an  excellent  recovery. 

CASE  XVII. — Acute  Suppuration  of  the  Right  Tympanum — Mastoid  Red,  Tender, 
and  Swelled — Fistula  Found — Enlarged — Relief — Still  under  Observation. — On 
March  1,  1887,  I  was  asked  by  Dr.  W.  A.  Dayton  to  see  a  female  child,  aged 
six,  with  the  following  aural  history  :  During  the  holidays  she  had  the  earache 
several  times,  generally  in  the  night,  with  some  regularity,  at  about  1  A.M. 
These  attacks  continued  at  intervals  until  February  22d,  when  they  became 
more  c<mstaftt.  Her  pulse  was  then  115.  Her  tongue  was  coated,  the  skin  dry. 
The  tympanum  discharged  very  moderately ;  the  mastoid  process  became  red, 
tender,  and  swelled.  Leeches  and  poultices  were  applied  with  only  partial  relief. 

On  March  1st  I  examined  the  ear.  I  found  the  drum-head  perforated,  caseous 
pus  lying  upon  its  remains,  the  mastoid  as  above  described.  I  advised  an 
incision  down  to  the  bone,  in  the  usual  way.  This  was  made  by  Dr.  Dayton  ; 
no  pus  was  found,  but  a  small  fistula  was  discovered  about  one-fourth  of  an  inch 
above  the  apex  of  the  mastoid,  with  softening  of  the  bone  about.  This  was 
enlarged  and  a  tent  introduced. 

March  2d. — The  relief  has  been  very  great. 

March  19th. — There  has  been  no  pain  since  the  operation.  The  wound, 
previously  syringed  with  weak  carbolized  water,  has  been  tightly  packed  every 
day  with  a  twelve-inch  tent. 

Granulations  have  sprung  up  in  the  wound  rapidly  ;  these  have  been  trimmed 
away  daily  with  curette  and  scissors.  The  use  of  a  four  per  cent,  solution  of 
•cocaine  has  rendered  the  treatment  almost  painless. 

There  has  been  no  pus  (from  the  beginning)  save  that  which  comes  away  on 
the  tent.  The  child  has  been  kept  in  bed,  in  a  bright,  sunshiny  room,  and 
allowed  a  generous  diet,  meats  only  prohibited. 

In  this  case  the  inflammation  has  been  rather  plastic  than  suppurative,  or 
predominantly^  of  the  former  character.  The  case  made  a  complete  recovery. 


518  CARIES   AND   ABSCESS   OF   MASTOID — CASES. 

CASE  XVIII. — Acute  Suppuration  of  the  Tympanum — Severe  Pain — Diplopia — 
Mastoid  Opened — No  Pus — No  Fistula — Recovery  in  Four  Months — Fistula  closed  in 

about  a  Year. — A.  M ,  aged  forty-six,  colored.    June  25, 1885.     For  five  weeks 

this  patient  states  that  he  has  suffered  from  a  purulent  discharge  from  the  left 
auditory  canal.  For  much  of  this  time  he  has  suffered  much  pain.  He  now 
has  a  suppuration  of  the  tympanum,  and  complains  of  severe  pain.  Two 
leeches  were  applied  to  the  tragus,  and  morphia  was  administered  hypoderini- 
cally  at  bedtime.  Warm  douche  to  the  canal. 

July  5th.— The  patient  has  been  very  comfortable  for  a  portion  of  the  time, 
but  he  has  had  considerable  pain ;  referred  to  the  left  side  of  the  head.  Be- 
sides the  hot  douche,  poultices  have  been  applied  about  the  ear  at  times.  It 
has  been  necessary  to  give  morphia  every  night.  The  discharge  has  been  pro- 
fuse. This  evening  his  temperature  is  101°. 

July  6th. — The  patient  has  homonymous  diplopia,  the  left  external  rectus 
being  paralyzed. 

July  7th. — Diplopia  and  pain  continued.  At  about  4  P.M.  the  mastoid  was 
opened  with  a  drill.  Dr.  Emerson  operated,  assisted  by  Dr.  Roosa.  No  pus, 
no  fistula  were  found.  A  tent  was  placed  in  the  opening  and  a  poultice  applied. 

July  9th. — The  patient  has  had  no  pain  since  the  operation.  Paralysis  of 
the  external  rectus  continues.  The  examination  with  the  ophthalmoscope  de- 
tects no  lesion  of  the  fundus  oculi. 

July  llth. — Yesterday  a  free  discharge  of  pus  occurred  from  the  mastoid 
cells.  He  also  had  pain  in  the  head  and  back  of  the  neck,  lasting  three  or  four 
hours.  This  is  the  first  since  the  operation,  and  at  5  P.M.  his  temperature 
was  much  higher  and  his  pulse  more  frequent  than  at  any  time  since  the  opera- 
tion. This  morning  he  is  sweating  profusely.  The  discharge  from  the  ear  is 
abundant. 

The  patient  was  taken  from  the  hospital  for  a  time,  but  reappeared  in  a  few 
days. 

August  6th. — He  is  now  up  and  about  his  room.  His  temperature  from  Au- 
gust 5th  to  the  12th  ranged  from  normal  in  the  morning  to  104°  in  the  after- 
noon. 

The  fistula  in  the  bone  is  free,  and  the  patient  has  no  pain. 

On  August  20th  the  patient  again  left  the  hospital.  He  reported  daily,  and 
was  readmitted  in  about  a  month.  The  granulations  were  removed  from  the 
sinus  by  a  curette,  and  the  opening  kept  free.  On  October  14th  he  was  dis- 
charged, without  pain  ;  the  diplopia  disappeared.  Some  thirty  days  since,  the 
fistula  still  existed.  The  patient  made  a  perfect  recovery,  and  is  still  living. 
The  fistula  closed  ;  abscesses  occurred  in  the  neck. 

In  another  case,  alluded  to  in  this  chapter,1  diplopia  also  oc- 
curred during  the  course  of  erysipelas,  which  supervened  upon 
the  operation  of  opening  the  mastoid.  It  is  remarkable  that  no 
pus  was  found  6n  opening  the  mastoid.  It  soon,  however,  made 
its  way  through,  and  the  fistula  thoroughly  drained  the  tympa- 
num, and  thus  gave  relief,  and  recovery  ensued.  I  can  but  think 
that  a  fatal  result  might  have  ensued  had  not  the  mastoid  been 
opened. 

1  Archives  of  Otology,  VoL  XII.,  1883. 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  519 

CASE  XIX. — Acute  Suppurative  Inflammation  of  the  Tympanum — Healing  of  the 
Drum-head  in  Two  Weeks — Masto id  Abscess — Removing  of  Pus — Opening  of  Mas- 
toid — Subsequently,  Deep  Abscesses  of  the  Neck — Recovery. — C.  P ,  aged  twenty- 
three.  Patient  was  admitted  to  the  hospital  on  September  3,  1886,  and  gave 
the  following  history : 

Three  months  previously  he  had  an  acute  suppuration  of  the  left  tympanum. 
The  drum-head  is  said  to  have  healed  in  two  weeks.  After  this  he  suffered  from 
severe  headaches  from  the  occiput  around  to  the  frontal  region.  A  swelling  be- 
hind the  ear  occurred  a  month  ago,  and  since  that  time  he  has  not  suffered 
much  from  pain.  The  mastoid  region  is  found  to  be  swollen,  but  not  red  or 
tender.  His  hearing  distance  is  -||>,  and  the  meinbrana  tympani  is  intact.  The 
neck  is  also  swollen  down  to  the  clavicle.  On  September  26th,  Dr.  Emerson 
opened  the  mastoid  cells  with  a  drill.  Pus  was  found  in  the  cells.  A  tent  and 
poultice  were  applied.  In  four  days  the  great  swelling  of  the  neck  had  sub- 
sided, and  pus  was  freely  discharging  from  the  opening  in  the  bone.  The  pa- 
tient is  anaemic  and  feeble.  Whiskey  and  iron  and  "milk  are  given.  The  swell- 
ing of  the  neck  reappeared  and  became  greater  than  before  the  operation.  An 
incision  along  the  sterno-cleido-mastoid  was  made  by  Dr.  Roosa  on  October  17th, 
and  a  careful  dissection  made  under  the  muscle,  and  a  large  quantity  of  pus 
evacuated.  lodoform  dressing  was  applied  and  a  rubber  drainage-tube  intro- 
duced. An  exploratory  incision  made  some  days  before  failed  to  find  pus,  but 
the  operation  of  to-day  showed  that  it  has  been  burrowing  for  a  long  time. 
From  this  time  the  patient  began  to  recover,  and  was  discharged  from  the  hos- 
pital on  December  10th,  with  one  drainage-tube  leading  down  to  the  bone,  but 
not  in  it.  For  a  long  time  previously  the  patient  had  three  drainage-tubes — 
one  into  the  fistula  of  the  mastoid,  one  along  the  side  of  the  sterno-cleido-mas- 
toid, and  one  over  the  border  of  the  occipital  bone.  For  some  time  they  com- 
municated with  each  other.  This  patient  finally  made  a  complete  recovery, 

The  marked  feature  in  this  case  was  the  complete  healing  of 
the  membrana  tympani  with  almost  complete  restoration  of  the 
hearing,  while  the  disease  went  on  in  the  mastoid  bone  and  ex- 
tended from  there  deep  into  the  cervical  tissue. 

CASE  XX. — Acute  Suppuration  of  the  Middle  Ear — Mastoid — Abscess — Fistula — 

Operation — Relief. — Bertha  X ,  aged  thirteen,  was  brought  to  me  by  her 

father,  a  physician,  February  28,  1885,  suffering  intensely  at  times  from  pain 
referred  to  the  left  ear.  The  history  states  that  she  had  severe  pain  in  the  ear 
on  the  Christmas-day  preceding,  and  that  the  ear  had  soon  begun  to  discharge 
pus,  and  that  it  has  continued  to  do  so.  The  hearing  distance  is  -c-.  The  bone 
conduction  is  better  than  the  aerial  on  that  side.  The  drum-head  is  gone  pos- 
teriorly, and  there  is  a  free  discharge  of  pus  from  the  tympanum.  The  mastoid 
region  is  red,  swollen,  and  tender.  The  mastoid  is  of  a  delicate  anaemic  type. 

On  the  same  day  the  mastoid  was  incised,  pus  evacuated,  a  fistula  leading 
into  the  tympanum  was  found  and  enlarged.  A  tent  was  applied.  Relief  to  the 
pain  soon  followed.  The  patient  was  treated  in  the  Manhattan  Eye  and  Ear 
Hospital  for  some  three,  months.  The  bone  about  the  fistula  was  found  ex- 
posed. The  fistula  was  enlarged  with  a  drill  at  the  time  of  the  operation,  and 
kept  open  by  the  use  of  the  curette  ;  granulations  sprang  up  very  readily. 

July,  1890.  ^The  fistula  healed  entirely  in  1888.     Patient  is  well. 


520  CAEIES   AND   ABSCESS   OF   MASTOID — CASES. 

The  prominent  feature  in  this  case  is  the  fact  that  the  fistula 
did  not  heal  in  a  year  after  the  operation.  This  may  have  been 
due  to  two  causes  :  1,  the  delicate  health  of  the  patien.t ;  2,  the 
care  of  the  patient  at  home — that  is,  in  regard  to  keeping  the  fis- 
tula and  tympanum  clear — has  not  been  quite  as  thorough  as 
when  the  patient  was  under  daily  treatment  at  the  hospital.  To 
keep  a  fistula  free  from  granulations  often  causes  so  much  pain 
that  a  tender  parent,  even  if  a  physician,  will  not  always  do  it. 

CASE  XXI. — Acute  Suppuration  of  the  Middle  Ear — Thickening  of  the  Tissues 
over  the  Mastoid — No  Tenderness  or   Pain — Recovery  u-ithout  Operation. — Mrs. 

H ,  aged  thirty-three,  was  brought  to  my  office  on  June  11,  1886,  by  Dr. 

John  C.  Peters,  who  desired  my  opinion  as  to  treatment  of  her  ear.  The  patient 
stated  that  some  twelve  weeks  before  she  was  seized  with  a  pain  in  the  right  ear. 
After  using  the  nasal  douche*  there  was  soon  a  discharge  of  pus  from  the  auditory 
canal,  which  has  continued  ever  since.  The  hearing  distance  on  the  right  side  is 
-^ ;  on  the  left,  ||.  At  times  she  has  considerable  pain  in  the  ear  and  the  right 
side  of  the  head.  The  tissues  over  the  mastoid  process  were  considerably 
thickened,  but  there  was  no  redness,  swelling,  or  tenderness.  The  drum-head 
was  perforate,  about  half  of  the  mernbrarre  being  gone,  and  there  was  a  free  but 
not  excessive  discharge  of  muco-pus.  The  patient,  who  was  a  well-developed 
woman,  appeared  to  be  in  a  high  state  of  nervous  excitement.  She  stated  that 
she  had  been  under  the  care  of  several  physicians,  and  that  this  morning  the 
last  one  whom  she  had  consulted  advised  that  the  mastoid  be  opened  to-day ; 
another  had  said  she  had  syphilis,  and  so  forth.  Before  she  had  made  the 
statement  in  regard  to  an  operation,  I  had  advised  Dr.  Peters  that  his  patient 
be  kept  in  her  room  and  that  the  ear  be  treated  by  the  use  of  the  warm  douche 
and  poultices,  the  latter  in  case  of  pain  ;  after  the  statement  as  to  the  urgent 
need  of  an  operation  I  again  went  over  the  case,  but  in  view  of  all  the  symptoms 
I  concluded  that  the  drainage  of  the  tympanum  was  sufficient,  and  that  what 
was  now  needed  was  absolute  mental  and  bodily  quiet.  The  patient  was  treated 
in  the  manner  indicated,  leeches  were  applied  to  the  tragus  the  next  day,  and 
poultices  were  used  in  front  and  behind  the  ear.  The  temperature  remained 
normal,  and  while  she  was  under  my  observation  (some  ten  days)  she  steadily  im- 
proved, and  finally  became  well  as  to  her  general  health  and  had  no  pain  referred 
to  her  ear.  There  remained  an  opening  of  the  membrana  tympani  when  she 
was  last  seen  by  me,  and  a  slight  muco-purulent  discharge,  but  I  have  been  in- 
formed by  her  mother,  within  a  few  days  of  writing  this,  that  the  patient,  now 
nine  months  since,  is  perfectly  well. 

In  this  case  the  patient's  natural  disposition  and  undisci- 
plined mind  led  her  to  exaggerate  her  symptoms,  especially  as 
regards  pain.  Then  again,  she  has  kept  herself  in  a  state  of  ex- 
citement by  running  about  to  various  physicians,  when  the 
actual  objective  conditions  were  really  not  at  all  grave.  At  any 
rate,  I  felt  that  with  a  tympanum  well  open,  a  mastoid  scarcely 
tender  on  the  very  firmest  pressure  upon  the  apex,  with  no  fever, 
and  a  brief  history  of  aural  disease,  in  a  person  excited  by  her 


CARIES   AND   ABSCESS   OF   MASTOID — CASES.  521 

frequent  change  in  advisers,  that  delay  was  certainly  proper. 
Much  as  I  advise  opening  the  mastoid  when  the  indications  are 
even  moderately  plain,  and  the  conditions  are  urgent,  I  am  al- 
ways very  anxious  not  to  perform  an  unnecessary  operation. 
The  case  belongs  to  the  same  class  as  Case  XIII. ,  and  the  one 
narrated  on  page  51 4,  and  before  alluded  to  in  this  article,  where 
neurotic  symptoms  predominated  over  the  inflammatory.  I 
ought  to  add  that,  after  a  thorough  examination,  neither  Dr. 
Peters  nor  myself  thought  the  patient  had  syphilis. 

If  operative  procedures  are  necessary  for  the  drainage  of  the 
tympanum,  certainly,  as  .a  rule,  they  are  best  and  most  safely 
performed  through  the  mastoid  cells.  In  some  instances  these 
may  be  best  reached,  however,  by  an  opening  in  the  auditory 
canal.  Such  an  operation  as  this,  however,  is  not  to  be  con- 
founded with  operations  which  aim  to  remove  the  remains  of 
the  drum-head  and  the  contents  of  the  tympanum.  Such  oper- 
ations may  be  indicated  in  cases  where  only  the  tympanum  is 
involved,  but  if  the  drainage  of  the  ear  is  insufficient,  and  the 
mastoid  cells  are  at  all  implicated,  opening  the  mastoid  is  a  much 
more  rational  and  less  difficult  operation  than  removal  of  the 
ossicles. 

All  of  us  know  that  even  the  operations  for  the  removal  of 
granulations  deeply  seated  in  the  tympanum  become  very  diffi- 
cult on  account  of  the  free  bleeding,  which  soon  renders  all 
exact  and  delicate  manipulation  almost  impossible. 

CASE  XXII. — Acute  Suppuration  of  the  Middle  Ear — Vertigo — Mastoid  Caries 

— Trephining — Fistula  Closed  in  Fifty-six  Days. — May  2,  1879.     Mr.  S ,  aged 

forty-seven.  Boiler-maker.  Has  been  hard  of  hearing  and  has  had  tinnitus 
"always."  Seven  weeks  ago  he  was  attacked  by  inflammation  in  the  ear,  caused 
by  exposure  to  cold  and  dampness.  He  now  has  suppuration  in  the  left  tym- 
panum, the  drum-head  being  perforate.  He  also  complains  of  vertigo  and 
shooting  pains  running  up  over  the  forehead,  down  toward  the  occiput.  H.  D., 
B.,  -fy.  The  warm  douche  and  poultices  behind  the  ear  were  advised.  In  a  day 
or  two  leeches  were  applied  on  the  tragus  and  upon  the  mastoid,  and  the  patient 
was  kept  very  quiet.  The  purulent  discharge  from  the  tympanum  is  free.  He 
has  slight  pain  in  the  tympanum  and  mastoid  at  night.  Quinine  was  used,  but 
without  benefit.  On  May  28th  he  was  having  rather  more  pain  and  vertigo,  the 
latter  only  when  moving  about.  Slight  tenderness  over  one  or  two  points  of 
the  mastoid  by  very  firm  pressure.  No  thickening  of  the  integument.  Copious 
discharge  from  the  ear.  The  canal  is  narrowed,  and  firm  granular  swelling  at 
the  bottom.  No  marks  of  drum-head  or  tympanum  visible.  Patient  can  attend 
to  business,  that  of  a  superintendent.  The  pain  is  intermittent.  An  incision, 
the  patient  not  being  under  anaesthesia,  about  one  inch  long  was  made  down  to 
the  bone.  The  bone  felt  softened  and  rough,  but  was  not  carious  except  at  one 
spot.  A  probe  was  worked  through  this  spot  until  it  penetrated  into  the  audi- 
tory canal.  The  opening  was  enlarged  with  the  drill.  No  pus  was  found.  The 


522  CARIES   AND    ABSCESS   OF   MASTOID — CASES. 

opening  was  plugged  with  lint  and  a  poultice  applied  around  the  ear.  The 
external  excision  was  made  T-shaped  before  the  drilling  was  undertaken.  The 
patient  had  some  pain  and  dizziness  until  midnight.  Absolute  rest  was  advised. 
There  is  no  fever.  The  patient  did  well  until  July  7th,  with  only  gradual  decrease 
of  vertigo  and  pain.  Last  night  he  had  an  increase  of  dizziness  and  a  feeling  of 
numbness  in  the  lips  on  the  left  side.  The  fistula  in  the  bone  has  been  closed 
for  a  week.  The  fistula  in  the  soft  tissues  is  still  kept  open.  The  canal  looks 
well,  and  there  is  only  a  moderate  discharge  from  the  tympanum.  The  air  is  felt 
in  the  ear  on  inflation,  but  there  has  been  no  perforative  whistle  for  the  last  few 
weeks. 

July  21st. — The  mastoid  fistula  has  closed.  Patient  feels  very  well.  H. 
D.,  ^  ;  voice,  50'. 

August  5th. — The  patient  has  been  in  the  country  since  last  date.  Has  had 
dizziness  for  about  ten  minutes  after  tipping  back  in  a  barber's  chair,  and  he 
also  suffers  from  it  if  he  tips  his  head  to  the  left,  or  lies  on  the  left  side.  No 
vertigo  in  walking. 

August  llth. — Frontal  headache  for  the  past  two  days.  More  dizziness. 
Numbness  of  the  left  side  of  the  nose  and  lip.  Nothing  wrong  seen  about  the 
ear.  Ordered  bromide  potash,  ten  grains  every  two  hours,  and  five  grains  ol 
blue  pill  to-night.  The  patient  recovered  from  this  attack,  took  a  voyage  to> 
England  and  back,  and  on  November  29th  he  was  seen  and  a  final  note  made- 
There  is  now  a  slight  purulent  discharge  from  the  tympanum.  He  had  a  slight 
bloody  discharge  from  it,  after  climbing  to  the  ball  of  St.  Paul's  Cathedral.  The 
upper  and  posterior  segments  of  the  membrana  tympani  are  now  cicatrized. 
An  opening  exists  below.  The  surface  scar  is  granular.  He  complains  of  sore- 
ness of  the  left  nostril  and  numbness  of  left  side  of  upper  lip  (see  August  llth).. 
Face  seems  a  little  drawn,  and  uvula  seems  to  tip  a  little  to  the  right  side.  The? 
patient  has  no  vertigo  or  pain. 

This  patient  was  hard  of  hearing  from  the  usual  cause  in  a 
boiler-maker,  but  upon  this  supervened  the  inflammation  of  the 
tympanum  and  mastoid.  The  inflammation  of  the  latter  was 
only  suppurative  in  a  very  narrow  track,  whatever  it  may  have 
been  in  other  parts.  The  tympanum,  as  shown  by  the  facial 
paresis,  was  markedly  affected.  The  first  positive  relief  to  his. 
pain  and  vertigo  came  from  the  enlargement  of  the  mastoid  fis- 
tula by  the  drill. 

CASE  XXIII. — Caries  of  the  Mastoid  from  Chronic  Suppuration — Exacerbation 

of  Otitis  Media — Mastoid   Opened  Three    Times— Recovery. — Miss  X ,   aged 

twenty-six.  January  11,  1877.  Six  years  ago,  patient  states  that  she  had  a  dis- 
charge from  the  left  ear  without  apparent  cause.  It  has  continued  more  or  less 
ever  since.  Last  September  she  took  cold,  and  had  severe  pain  with  delirium. 
Swelling  of  the  mastoid  occurred,  and  in  the  last  week  of  September  it  was- 
cut.  A  free  discharge  of  pus  occurred  and  relief  of  the  pain.  The  incision 
healed  in  a  few  days  and  the  pain  returned.  The  mastoid  cells  "  were  pierced  "" 
in  October.  The  patient  comes  to  me  on  account  of  continued  pain  and  occa- 
sional dizziness.  The  left  auditory  canal  is  red,  sensitive,  and  full  of  pus. 
There  is  a  large  cicatrix  on  the  mastoid  and  a  sinus  running  downward  and  for- 


CARIES   AND  ABSCESS  OF  MASTOID— CASES.  523 

ward  toward  the  auditory  canal.  The  physician  who  opened  the  bone  afterward, 
wrote  me  as  follows  :  "  I  found  a  fistulous  opening  where  the  mastoid  had  pre- 
viously been  lanced.  I  at  once  made  a  free  opening  through  the  soft  tissues 
into  the  cells.  No  pus  was  found.  A  fistulous  opening  existed  between  the 
osseous  and  cartilaginous  meatus  down  quite  into  the  middle  ear.  The  opera- 
tion afforded  very  great  relief  from  the  urgent  symptoms.  But  as  the  wound 
contracted  pain  recurred." 

About  a  month  after,  the  Doctor  again  opened  the  wound,  cut  away  as  much 
of  the  diseased  tissue  as  possible  with  a  chisel,  following  the  fistulous  track. 
The  probe  detected  diseased  bone  at  the  depth  of  one  and  one-quarter  inch. 
Relief  again  occun-ed.  Some  time  after,  a  small  piece  of  bone  came  away.  The 
wound  closed,  but  on  January  6th  swelling  and  pain  in  the  mastoid  again  be- 
gan. The  next  day  the  wound  again  opened,  and  at  this  point  she  came  under 
my  care.  After  vainly  attempting  to  get  permanent  relief  from  the  pain,  by 
keeping  the  fistula  open  with  a  tent,  and  treating  the  tympanum  through  the 
auditory  canal,  I  determined  to  open  the  wound  freely  and  enlarge  the  bone 
fistula.  Accordingly,  on  April  7th,  the  patient  was  etherized.  The  external 
opening  was  enlarged,  and  the  surface  of  the  bone  carefully  examined.  It  was 
found  to  be  smooth.  The  fistulous  opening  into  the  tympanum  through  the 
osseous  canal  was  then  enlarged  with  a  drill,  and  the  outer  opening  was  made 
funnel-shaped.  The  fistula  was  treated  by  being  dressed  to  the  bottom  with  a 
tent,  and  healed  June  23d,  a  little  more  than  two  months  after  the  opening  had 
been  enlarged.  The  patient  hao-  been  free  from  pain  since  a  few  days  after  the 
operation.  The  tympanum  was  treated  through  the  auditory  canal,  by  thorough 
cleansing  with  a  syringe  and  curette,  there  being  a  great  disposition  to  the  in- 
spissation  of  pus  and  the  formation  of  granulations,  but  she  finally  entered  upon 
her  duties  as  a  teacher,  which  she  continues  (June,  1884)  to  perform.  When 
last  seen,  in  1882,  a  part  of  a  cicatricial  membrana  tympani  existed,  there  was  a 
free  dischai-ge  from  the  tympanum,  and  a  granulation  in  the  upper  part.  Under 
the  use  of  iodoform  this  became  better. 

The  final  success  in  this  obstinate  case  was  due,  I  think,  to  a 
persistent  care  of  the  tympanic  cavity,  which  was  left  free  from 
pus  and  granulations,  while  the  osseous  fistula  was  being  healed 
from  the  bottom.  In  opening  the  mastoid,  the  surgeon  should 
remember  that  the  operation  has  become  necessary  because  the 
pus  is  not  thoroughly  evacuated  from  the  tympanum  through 
the  canal.  There  will,  therefore,  often  be  found  much  to  be 
done  in  treatment  of  the  canal  and  tympanum. 

The  following  case  occurred  in  my  own  clinic,  and  although 
treated  mainly  by  Dr.  Ely  and  Dr.  Brown,  I  saw  the  patient 
frequently,  and  advised  in  the  later  stages  of  treatment.  It  was 
reported  by  Dr.  F.  Tilden  Brown  in  -a  special  journal,1  but  it  is 
of  sufficient  importance  to  be  inserted  here,  since  it  illustrates 
what  has  been  said  of  the  occasional  difficulty  in  diagnosis  as  to 
the  presence  of  pus  in  the  mastoid  cells. 

1  Archives  of  Otology,  vol.  xii.,  1883. 


524  CARIES   AND   ABSCESS   OF   MASTOID — CASES. 

CASE  XXTV. — A  Case  of  Abscess  of  the  Mastoid,  with  Entire  Absence  of  Tender- 
ness, Heat,  en-  Swelling  over  the  Suppurating  Part,  with  a  constant  Distant  Pain  near 
the  Occipital  Protuberance — Trephining — Recovery — Occurrence  of  Erysipelas  dur- 
ing Convalescence. — John  M ,  aged  forty-eight,  came  to  Dr.  Roosa's  clinic 

at  the  Manhattan  Eye  and  Ear  Hospital  on  September  14,  1882.  Examination 
by  Drs.  Edward  T.  Ely  and  F.  T.  Brown  showed  a  muco-purulent  discharge 
from  the  right  ear,  partial  loss  of  the  membrana  tympani,  diminished  calibre  of 
the  auditory  canal,  no  swelling  or  redness  behind  the  auricle,  no  tenderness  on 
pressure  or  percussion  over  the  mastoid,  inability  to  hear  a  watch  on  contact,  tun- 
ing-fork heard  but  by  aerial  conduction.  The  sole  cause  of  his  coming  to  the 
hospital  was  great  pain  at  a  point  along  the  right  superior  curved  line,  two 
centimetres  from  the  occipital  protuberance ;  occasionally  radiating  along  the 
right  border  of  the  parietal  suture  over  the  frontal  bone  to  its  interior  angular 
process ;  thence  above  and  below  the  orbit. 

Previous  History. — No  direct  injury,  but  had  a  fall  on  back  of  head  one  month 
before.  Had  never  had  syphilis  ;  was  perfectly  temperate,  and  had  always  been 
well  until  the  fourth  of  last  June,  when  he  experienced  gradually  increasing 
pain  in  the  right  ear.  Morphine  gave  temporary  relief.  Five  days  after,  a  dis- 
charge appeared.  The  pain  continuing,  a  blister  was  applied  behind  the  ear, 
and  on  June  16th,  he  was  able  to  go  to  work,  but  returned  in  a  few  hours  with 
still  greater  pain.  For  the  three  weeks  following  morphine  (hypodermically) 
was  given  twice  daily;  this  failing,  chloroform  inhalation  was  resorted  to.  Late 
in  July,  Wilde's  incision  was  made  at  the  New  York  Eye  and  Ear  Infirmary,  but 
the  pain  became,  almost  at  once,  more  intense.  A  few  days  later  a  bone-opera- 
tion was  proposed,  but  the  patient's  family  objecting,  he  came  with  a  letter  from 
his  physician  to  the  Manhattan  Eye  and  Ear  Hospital.  Here  careful  watching 
for  two  days  and  nights  verified  his  story  of  pain,  sleeplessness,  and  loss  of 
appetite,  but  no  abnormal  temperature  was  detected. 

The  result  of  a  consultation  was  to  defer  operation  until  thorough  anti-neu- 
ralgic treatment  had  been  tried.  Quinine,  alcohol,  and  galvanism  were  ordered. 
Five  days  later  the  patient  was  no  better,  and  perforation  of  the  mastoid  was 
determined  upon  despite  the  absence  of  satisfactory  local  symptoms.  It  was 
performed  by  myself  under  the  advice  of  Dr.  Ely.  The  periosteum  was  healthy, 
and  on  its  section  the  bone  presented  a  similar  appearance.  Brainerd's  drill 
sunk  one  and  a  half  centimetre,  entered  a  cavity,  when  about  four  grammes  of 
pus  came  away.  A  warm  solution  of  boracic  acid,  thrown  into  the  meatus  audi- 
torius,  found  exit  through  the  wound,  bringing  pus.  The  dressing  was  antiseptic 
and  directed  to  favor  free  drainage  and  prevent  occlusion.  Pain  was  at  once 
and  permanently  removed.  Two  weeks  later  the  patient  went  home,  but  returned 
daily  for  dressing.  The  discharge  now  amounted  to  three  grammes  in  twenty- 
four  hours,  and  a  watch  could  be  heard  on  contact.  On  the  evening  of  Novem- 
ber 4th,  pain  was  felt  about  the  auricle,  followed  by  a  chill  with  subsequent 
fever ;  the  pain  prompted  a  vigorous  application  of  camphorated  oil.  Toward 
morning  the  patient  vomited.  I  was  sent  for  the  following  night,  when  I  found 
him  with  a  pulse  of  90 ;  temperature,  103° ;  tongue  coated  ;  bowels  constipated  ; 
pupils  normal  in  response  to  light.  Probe  passed  readily,  but  the  discharge 
was  slight.  The  tissues  about  the  wound  and  over  the  parotid  region  were 
oadematous  and  but  slightly  sensitive  ;  this  pallor  suggested  serous  rather  than 
haemostatic  injection,  and  might  have  been  either  the  erysipelatous  cause,  or 
the  blistering  effect,  of  camphorated  oil  applied  to  relieve  deeper  pain.  The 


CAEIES   AND   ABSCESS   OF   MASTOID — CASES.  525 

diagnosis  of  erysipelas  was  made  on  the  fourth  day ;  this  disease,  still  indiffer- 
ently marked,  had  extended  to  the  left  malar  bone  ;  pulse  was  98  ;  temperature, 
103|°;  delirious  through  the  night ;  sight  was  indistinct ;  had  convergent  squint ; 
pupils  responded  feebly  to  light ;  had  moderately  rhythmic  vibrations  of  the  right 
forearm.  I  was  again  led  to  doubt  the  absence  of  meningitis,  and  called  Dr. 
Boosa  in  consultation,  who,  on  examination,  found  slight  cerebral  impairment 
and  homonymous  double  vision  existing  ;  the  ocular  media  were  clear.  Optic 
disks  not  seen  on  account  of  want  of  illumination.  The  mastoid  perforation  was 
free,  and  afforded  no  evidence  of  retained  pus,  although  the  discharge  was 
greatly  diminished.  For  this  reason  Dr.  Boosa  and  myself  concluded  that 
meningitis  due  to  adjacent  suppurative  mastoid  disease  did  not  exist,  and  that 
the  diplopia,  with  other  nervous  symptoms,  was  due  to  a  peripheral  hypersemia 
of  the  pia  mater,  by  continuity  of  tissue  with  the  facial  erysipelas,  resulting  in 
irritation  of  the  sixth  nerve  at  its  point  of  exit. 

This  belief  proved  to  be  correct,  for  the  intensity  of  the  symptoms  subsided, 
and  in  eight  days  convalescence  began.  The  discharges  from  both  channels  had 
ceased,  and  one  week  later  the  wound  completely  closed.  This  was  an  agree- 
able surprise,  for  in  its  relationship  to  disease  of  the  mastoid,  I  viewed  the 
erysipelas  as  analogous  to  epididymitis  succeeding  a  gonorrhoaa,  and  I  expected 
a  return  of  the  discharge  as  the  erysipelas  subsided. 

Dr.  Brown  gave  the  following  points  as  being  of  special 
interest  in  this  case  : 

1.  The  entire  absence  of  tenderness,  heat,  or  swelling  over 
the  suppurating  mastoid,  while  there  was  a  constant  pain  re- 
ferred to  a  point  near  the  occipital  protuberance. 

2.  The  difficulty  in   differentiating  the  symptoms  of  facial 
erysipelas  from  those  of  meningitis. 

3.  The  direct  suggestion  made  by  the  case,  of  the  value  of 
active  counter-irritation  in  the  treatment  of  sub-acute  or  chronic 
suppuration  of  the  middle  ear. 

I  lately  had  under  treatment  at  the  hospital,  a  man,  aged 
forty-five,  upon  whom  I  performed  the  operation  of  trephin- 
ing the  mastoid  process  for  caries  and  abscess,  in  whom  facial 
erysipelas  developed  in  three  days  after  the  operation.  Al- 
though he  became  very  ill,  having  for  some  time  a  temperature 
of  105°,  he  recovered.  The  mastoid  caries  occurred  during  the 
course  of  acute  suppuration  of  the  middle  ear,  which  he  very 
much  neglected.  Although  the  patient  was  three  weeks  in 
bed  from  the  facial  erysipelas,  the  occurrence  of  this  disease 
hardly  seemed  to  retard  the  recovery  of  the  abscess  of  the 
mastoid. 

Besides  the  dangers  of  erysipelas  and  pyaemia  from  suppura- 
tive inflammation  of  the  mastoid,  it  is  not  uncommon  to  meet 
with  inflammation  of  the  connective  tissue  of  the  neck,  with 
the  formation  of  abscesses.  In  one  of  my  cases  the  life  of  the 


526 


CARIES   AND   ABSCESS   OF  MASTOID— CASES. 


patient  was  at  one  time  threatened  by  the  numerous  abscesses, 
and  his  swallowing  was  for  some  days  extremely  difficult  on 
account  of  the  pressure  upon  the  pharynx. 

Table  Showing  the  Relative  Frequency  of  Affections  of  the  Mastoid  in  Certain  Eye 
and  Ear  Hospitals,  and  in  the  Writer's  Private  Practice. 


Name  of  Institution. 

Total  Num- 
ber of  aural 
cases. 

Num- 
ber   of 
years. 

Affections 
of  the 

mastoid. 

Operations. 

Manhattan  Eye  and  Ear 

14,720 

17 

110 

Wilde's  incisions  and  open- 

Hospital. 

ing    of    mastoid,     105. 

• 

(Wilde's  incision,  94.     En- 

largement of  a  fistula,   5. 

Perforation,  6.)     One  open- 

ing through  auditory  canal. 

Brooklyn  Eye  and  Ear 

18,366 

18 

91 

126    Wilde's    incisions    and 

Hospital. 

>. 

perforations    of    the    mas- 

toid. 

New  York   Ophthalmic 

14,634 

17 

112 

Wilde's  incisions,  108.     Per- 

and Aural  Institute. 

forations   of    the    mastoid, 

22.     Opening  through  au- 

ditory canal,  1.    Total,  131. 

Massachusetts    Chari- 

9,533 

3 

62 

Operations    not  fully  re- 

table Eye  and  Ear  In- 

corded. 

firmary. 

Newark  Charitable  Eye 

3,021 

3 

22 

15 

and  Ear  Infirmary. 

Illinois  Eye  and  Ear  In- 

2,464 

4 

8 

16 

firmary. 

New  York  Charity  Hos- 

20 

1 

1 

1 

pital. 

Author's  Private    Prac- 

5,797 

22 

59 

42 

tice. 

Percentage  of  Affections  of  the  Mastoid. 


Aural  cases. 

Mastoid  cases. 

Per  cent. 

14,720 

109 

0.74 

18,366 

91 

0.49 

14,634 

112 

0.76 

9,533 

62 

0.65 

3,021 

22 

0.72 

2,464 

8 

0.32 

20 

1 

0.05 

5,797 

59 

1.01 

68,555 

464 

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536  HISTORY   OF   MASTOID   OPERATIONS. 


HISTORICAL  SKETCH  OP   OPERATIONS  UPON  THE  MASTOID  PROCESS. 

It  is  now  about  a  hundred  years,  since  a  Danish  surgeon, 
Berger,  of  Copenhagen,  who  evidently  suffered  from  chronic 
non-suppurative  inflammation  of  the  tympanum,  or  from  dis- 
ease of  the  labyrinth,  misled  by  the  indications  laid  down 
by  the  surgeons  of  his  time,  died  from  meningitis  induced 
by  an  operation  for  perforation  of  the  mastoid  process.  "  A 
martyr  to  the  operation,"  says  one  of  the  writers  of  his  day. 
Beck '  states  that  Berger  was  old  and  deaf,  and  that  after  the 
bone  was  opened  injections  would  not  pass  through  the  opening 
into  the  nose  or  mouth.  Fever,  sleeplessness,  vomiting,  and  de- 
lirium followed,  and  the  patient  died  in  eleven  days.  There 
was  suppurative  meningitis.  Where  the  bone  was  opened  it 
was  two  lines  in  thickness,  while  the  perforator  entered  for  five 
lines. 

Like  perforation  of  the  membrana  tympani,  trephining  the 
mastoid,  having  been  successfully  performed  under  proper  in- 
dications, was  widely  recommended  for  cases  for  which  it  could 
do  but  harm,  and  poor  Berger's  life  paid  the  penalty  for  a  want 
of  knowledge  on  the  part  of  the  surgical  writers  of  his  day.  If 
the  operation  had  been  performed  many  times,  in  such  cases 
as  those  of  Dr.  Berger's,  there  would  have  been  many  more 
martyrs. 

A  regimental  surgeon,  Jasser,  in  1776,  performed  the  opera- 
tion upon  the  ear  of  a  soldier  who  had  suffered  long  from  a 
chronic  suppuration  with  occasional  acute  attacks  attended  by 
great  pain.  The  mastoid  was  swelled  :  the  patient  was  half 
insane  with  pain.  Jasser  made  an  incision  on  the  mastoid  about 
an  inch  long  and  found  a  drop  of  pus.  Encouraged  by  this,  he 
cut  down  upon  the  whole  length  of  the  mastoid  bone.  He  found 
the  surface  roughened.  With  a  probe  he  went  quite  deeply  into 
the  mastoid  cells.  He  injected  fluid  into  the  opening ;  it  came 
out  of  the  nose,  and,  at  the  same  time,  a  large  quantity  of  pus 
was  discharged  from  the  external  meatus.  The  patient  im- 
mediately exclaimed  that  the  pain  had  left  his  ears.  He  went 
quickly  to  sleep  and  rested  uninterruptedly  for  ten  hours.  In 
three  weeks  the  opening  behind  the  ear  had  healed,  the  discharge 
from  the  auditory  canal  had  ceased,  and  the  patient  heard 
better  than  before.  Stimulated  by  this,  Jasser  performed  the 
same  operation  upon  the  same  person,  upon  the  other  ear,  from 
which  there  was  no  discharge,  but  in  which  the  hearing  was 

1  Handbuch,  p.  60. 


HISTORY   OF   MASTOID   OPERATIONS.  537 

impaired.  Here  the  hearing  is  said  to  have  also  been  improved, 
although  there  was  no  caries  of  the  bone.  The  operation  got  its 
name  from  Jasser,  although,  as  every  medical  reader  knows,  it 
had  been  proposed  by  Riolanus  more  than  a  hundred  years 
before  Jasser's  time,  and  Petit  had  opened  a  mastoid  with  a 
gouge  and  hammer  in  1750.  The  first  named  had  proposed  the 
operation  for  deafness  and  tinnitus  caused  by  stoppage  of  the 
Eustachian  tube. 

Then  we  come  to  Valsalva's  case,  published  nearly  a  hundred 
years  after  the  suggestion  of  Riolanus,  which  has  been  claimed 
by  all  the  authors  as  a  case  of  perforation  of  the  mastoid,  and  in- 
jection through  it  of  the  middle  ear.  One  writer  (Von  Troltsch) 
states  that  an  otorrhcea  was  thus  cured  by  Valsalva.  I  have 
examined  the  original  passage  in  order  to  verify  this  claim  made 
for  Valsalva,  and  I  find  that  there  is  no  such  claim  by  Valsalva 
himself.  He  simply  states  that  he  injected  a  fistula  existing  in 
this  part,  in  the  case  of  a  nobleman  ;  with  what  result  he  does 
not  say.  The  folio  wing  is  the  side-note  to  the  passage  : '  "  Obser- 
vatio  ulceris  adprocessum  mamillarem,  per  quod  injecta,  statim 
in  oris  cavitatem,  licet  undequaque  illcesam  transmittebantur." 
The  passage  itself  is  as  follows  :  "  Adeoque  mitto  prolixius  con- 
firmare  per  quondam  meam  in  vivo  homine  observationem,  de 
nobili  scilicet  viro,  ulcere  ad  processum  mamillarem,  cum  hujus 
carie  laborante  in  quod  quce  injiciebantur,  illico  ad  fauces  per- 
veniebant  adeoque  a  tympano,  quo  per  illius  processus  sinuosi- 
tates  ascendebant,  per  tubam  certe  derivebantur,"  etc. 

This  passage  may  be  translated  as  follows.  After  speaking 
of  the  Eustachian  tube  as  a  passage  to  the  pharynx,  Valsalva 
says :  "  I  beg  to  confirm  what  I  have  said,  by  an  observation 
made  on  the  living  subject,  a  nobleman,  who  was  affected  with 
caries  of  the  mastoid  process.  The  fluids  that  were  injected  intc- 
this  ulcer  passed  through  the  sinuosities  of  the  mastoid  process 
into  the  tympanum,  and  thence  through  the  tube  to  the  fauces." 
Valsalva  is  here  demonstrating  the  function  of  the  Eusta- 
chian tube.  He  makes  no  claim  to  have  perforated  the  mastoid, 
but  he  simply  asserts  that  he  has  injected  a  fistula  in  the  mas- 
toid, and  that  the  fluid  thus  injected  passed  into  the  mouth.  I 
cannot  find  any  evidence  in  the  passage  or  the  context  that  his 
patient  was  cured  of  an  obstinate  otorrhcea,  as  asserted  by  Von 
Troltsch,  so  that  I  think  Valsalva  must  be  left  out,  so  far  as  any 
evidence  from  this  passage  goes,  in  the  enumeration  of  those 
who  have  recommended  or  performed  the  operation  of  which  we 
are  speaking. 

'Tractatus  de  aure  Humana,  1742,  p.  89. 


538  HISTOKY   OF   MASTOID   OPERATIONS. 

Morgagni    declaimed  against    the  operation,   not  on    good 
grounds,  however,  but  because  he  supposed  there  was  no  open- 
ing of  the  mastoid  cells  into  the  tympanum.     Petit,  however, 
recommended  the  operation  for  caries  and  abscess  of  the  mas- 
toid.    Jasser  seems  to  have  lost  his  head  after  his  first  properly 
performed  and  successful  case,  and  he  probably  was  the  cause 
of  the  widely  spread  recommendations  of  this  surgical  procedure 
for  all  kinds  of  aural  cases.     If  Jasser  had  rightly  understood 
the  indications  for  opening  the  mastoid — indications  which  were 
plain  in  his  first  case  and  which  were  not  to  be  found  in  the 
second, — a  valuable  surgical  procedure  would  not  have  been 
practically  ignored  by  the  profession  for  nearly  fifty  years.     It 
required  about  this  length  of  time  before  surgeons  would  "med- 
dle with  the  mastoid."      The  operation   was,   however,  occa- 
sionally performed  by  independent  surgeons,  when  pus  was  evi- 
dently retained  in  the  bone,  but  very  few  reports  are  found  of 
these  cases.     Troltsch  '  finds  seven  cases  prior  to  1858.     In  the 
operative  surgery  of  Sir  Charles  Bell,2  as  early  as  1812,  he  says  : 
"  We  learn  from  this  view  of  the  subject  how  carefully  we  ought 
to  attend  to  symptoms  when  there  is  disease  of  the  ear,  lest  it 
should  become  irrevocably  bad,  and  end  in  communicating  the 
disease  to  the  brain.    We  must  bleed  and  purge  and  foment  to 
allay  the  pain  and  inflammation  if  it'  be  active,     .     .     .     and 
when  we  can  ascertain  that  there  is  caries  in  the  posterior  angle 
of  the  bone,  with  danger  of  the  confinement  urging  the  progress 
of  the  diseased  action  of  the  brain,  we  have  to  apply  the  trephine 
and  penetrate  into  the  cells  of  the  bone."    But  here,  as  in  all  the 
writings  until  our  own  generation,  there  is  a  notable  absence  of 
any  careful  account  of  the  early  symptoms  of  mastoid  disease. 
No  one  would  be  able  from  these  general  descriptions  to  diagnos- 
ticate and  successfully  treat  the  early  stages  of  the  affection. 
Dieffenbach,3  in  1848,  utterly  condemns  the  operation,  and  agrees 
with  Itard  in  saying  that  it  should  be  entirely  abandoned.     He 
believes  that  a  carious  process  would  be  increased  by  opening 
the  bone.    As  great  a  man  as  Sir  William  Wilde  *  evidently  does 
not  understand  that  the  bone  ought  to  be  opened  under  certain 
circumstances.     He  alludes  to  artificial  perforations  of  the  pro- 
cess for  the  purpose  of  throwing  injections  into  the  middle  ear, 
or  to  relieve  deafness  in  cases  where  the  Eustachian  tube  had 
been  closed, — an  operation,  he  continues,  which  has  long  since 
been  exploded,  not  only  as  ineffectual  but  positively  hazardous. 

1  Virchow's  Archiv,  1861. 

*  A  System  of  Operative  Surgery,  first  American  edition. 

8  Troltsch' s  Lehrbuch  Sechste  Auplage,  p.  499. 

4  Text  book,  p.  363,  English  edition. 


WILDE'S  INCISION.  539 

Although  he  had  given  a  name  to  an  incision  through  the  peri- 
osteum of  the  mastoid  for  the  relief  of  periostitis  of  this  part, 
and  although  he  alludes  to  fistulas  being  formed  in  this  bone  in 
the  course  of  chronic  suppuration,  he  gives  no  sign  that  there 
might  be  cases  in  which  it  would  be  wise  to  go  farther  than  the 
periosteum  and  open  the  bone.  Indeed,  in  many  cases  where 
Wilde's  incision  was  performed,  a  little  search  would  have  found 
an  opening  that  nature  was  trying  to  make.  But  the  improper 
indications  of  "  closing  of  the  Eustachian  tube,  tinnitus  aurium, 
deafness,"  were  so  confounded  with  the  one  proper  one  of  reten- 
tion of  pus,  that  even  Wilde  could  not  separate  them. 

Toynbee  had  a  very  large  experience  in  fatal  cases  of  mas- 
toid disease,  and  yet  all  he  has  to  say  upon  the  subject  of  the 
operation  is  :  "  Perforation  of  the  mastoid  process  also  suggests 
itself,  and  this  operation  may  doubtless  be  performed  in  those 
cases,  when  the  matter  is  pent  up  in  the  cavity  of  the  ear,  and 
is  causing  such  urgent  and  serious  symptoms  as  are  likely,  if 
not  relieved,  to  terminate  in  death.  I  have  never  performed 
this  operation,  but  I  should  not  scruple  to  dp  so  in  a  case  in 
which  the  life  of  the  patient  was  threatened."  ' 

Good  surgeons  everywhere  followed  Wilde  in  his  advocacy 
of  a  free  and  deep  incision  down  to  the  bone.  In  this  city,  the 
late  Professor  Post  regularly  lectured  upon  affections  of  the 
mastoid,  and  often  made  Wilde's  incision,  but  he  also  considered 
the  operation  of  opening  the  process,  as  one  only  or  chiefly  re- 
commended for  affections  where  it  would  be  useless  if  'not 
dangerous. 

Prompted  by  a  happy  experience  into  which  he  entered 
rather  timidly,  Troltsch  in  1861  published  a  paper  in  Virchoiv's 
Archives  upon  the  subject  of  perforations  of  the  mastoid,  which 
probably  did  more  than  any  other  one  thing,  to  bring  the  sub- 
ject clearly  before  the  profession.  He  there  reports  a  ca.se  in 
which  he  had,  in  1858,  perforated  the  mastoid  with  a  blunt  probe. 
He  collected  the  scattered  cases  from  the  literature  of  the 
subject,  and  seems  to  have  been  the  first  writer  after  Berger's 
martyrdom,  who  was  wise  enough  to  show  that  opening  an 
ulcerated  mastoid  to  remove  dead  bone,  concealed  pus,  and 
secure  thorough  drainage,  was  a  proper  and  often  necessary 
operation.  According  to  Troltsch's  own  words,  although  the 
indications  would  now  be  considered  imperative  and  clear,  he 
opened  the  softened  mastoid  with  fear  and  trembling.  He  says  : 
"  I  went  to  work  with  uncommon  care,  even  with  dread." 

Troltsch's  case  was  one  of  those  that   I   have  found  more 


Disease  of  the  Ear,  London,  1860,  p.  341. 


540  OPENING  THE   MASTOID. 

frequently  than  any  other — that  is  to  say,  one  in  which  a  fistula 
had  been  made  in  the  bone  by  the  suppurative  process. 

Troltsch  seems  to  have  hesitated  after  making  a  Wilde's  in- 
cision. He  looked  up  the  accessible  literature  of  the  subject, 
and  he  found  some  cases  where  life  was  apparently  saved  by 
the  operation.  All  the  authorities,  however,  were  in  doubt 
about  the  propriety  of  performing  it,  and  he  continues  : 

''What  was  more  natural  than  that  such  an  operation  ap- 
peared to  one  who  had  scarcely  practised  medicine  for  a  year,  as 
an  affair  to  be  well  weighed,  and  that  I  treated  the  case  with 
great  circumspection  and  almost  in  an  experimental  manner." 
"  I  think,"  he  says,  "  if  I  had  not  achieved  my  end  with  a  simple 
probe,  then  I  would  scarcely  have  desired  to  act  more  vigorously 
with  other  instruments."  But  Troltsch  had  been  a  student  of  the 
great  Irishman.  He  had  often  seen  him  divide  a  red,  tender, 
painful,  and  swelled  mastoid  down  to  the  bone,  and  he  imitated 
him  in  this  case,  and  in  spite  of  the  authorities,  in  two  days  he 
went  farther,  when  the  pus  escaped  and  relieved  the  sufferings 
of  his  patient. 

In  February,  1862,  Lawrence  Turnbull1  published  two  cases 
in  which  he  made  an  incision  down  to  the  bone,  and  a  third  in 
which  two  months  after  he  had  opened  the  external  tissues,  he 
perforated  the  surface  of  the  bone  with  a  sharp  hollow  probe, 
and  applied  nitrate  of  silver  freely.  A  month  later  he  again 
broke  down  a  part  of  the  bone,  and  nineteen  days  later  he 
removed  a  large  piece  of  bone,  which  was  found  to  be  movable 
with  the  probe.  This  was  an  operation  very  like  that  of  Troltsch, 
although  the  German  surgeon  only  waited  a  few  days  before 
venturing  to  go  into  the  cells  with  a  probe,  while  the  American 
delayed  for  two  months.  In  spite  of  its  exclusion  from  some 
tables,  TurnbulPs  case  belongs  to  the  same  category  with  that 
of  the  reviver  of  the  operation.  It  was  operated  upon  but  three 
years  after  Troltsch's  case,  and  only  one  year  after  it  was 
published. 

In  1863  Pagenstecher  *  published  two  cases,  with  some  re- 
marks upon  the  nature  of  affections  requiring  the  opening  of 
the  mastoid.  He  declares  the  technique  of  the  operation  to  be 
simple  and  easily  acquired.  This  is  an  article  written  in  a  truly 
surgical  spirit.  In  1868  James  Hinton  reported  3  a  case  in  which 
he  perforated  the  mastoid  cells  with  a  trocar,  the  next  day 
after  he  had  made  an  incision  through  the  periosteum.  The 


1  Philadelphia  Medical  and  Surgical  Reporter,  vol.  vii.,  p.  463. 
•  Archiv  fur  kliniche  Chirurgie,  Bd.  iv. ,  p.  322. 
3  Times  and  Gazette,  London,  vol.  ii.,  p.  378. 


OPENING   THE   MASTOID.  541 

case  was  one  of  chronic  suppuration  of  the  tympanum.  Mr. 
Hinton  speaks  of  fourteen  cases  of  perforation  of  the  mas- 
toid  for  the  evacuating  of  matter  reported  by  various  authors. 
Twelve  he  says  were  successful.  In  one  of  the  fatal  ones 
pyaemia  occurred.  He  says  the  operation  is  suitable  to  two 
classes  of  cases  :  1,  Those  in  which  the  matter  collects  in  the 
dependent  mastoid  cells  ;  2,  those  in  which  caries  takes  place 
in  the  roof  of  the  pyramid.  He  recommends  the  centre  of  the 
mastoid  for  perforation  in  the  former  case,  and  in  the  latter 
the  upper  part  of  it,  about  on  a  level  with  the  roof  of  the  meatus. 
His  recommendations  are  evidently  inspired  somewhat  by  Pa- 
genstecher's  paper. 

In  1864  A.  B.  Crosby,  living  in  the  mountains  of  New  Hamp- 
shire, probably  not  knowing  of  Troltsch's  writings,  but  perhaps 
having  Sir  Charles  Bell's  sound  advice  in  mind,  opened  the  mas- 
toid, in  three  cases  where  he  suspected  the  presence  of  pus,  with 
a  gimlet.  Although  this  was  in  1864,  the  cases  did  not  get  to 
general  professional  knowledge  until  1873.  Relief  was  given  in 
all  the  cases.  Some  years  after,  in  1872,  I  was  present  when 
Agnew  again  opened  one  of  these  gimlet  cases  and  found  a  scle- 
rosed  condition  of  the  bone,  one  well  known  to  the  early  writers. 

By  this  time,  1864,  the  operation  begins  to  be  freely  spoken 
of.  Ludwig  Mayer,  of  Worms,  Jacoby,  of  Breslau,  Follin, 
and  others  reported  cases.  Jacoby  had  a  considerable  experi- 
ence, and  wrote  two  or  more  valuable  papers  in  the  Archives 
of  Otology.  He  proposed  instruments,  gave  tables,  and  so 
forth. 

Schwartze  first  appears  in  the  literature  on  this  subject  in 
1864  (Praktische  Beitrage,  1864),  as  having,  some  days  after  he 
had  made  a  Wilde's  incision,  opened  the  roughened  exposed 
bone  with  a  probe,  in  the  case  of  a  child  aged  one  year  and  a 
quarter.  The  bone,  he  says,  was  very  easily  perforated.  In 
August,  1869,  he,  with  Koppe,  reported  a  case  of  reflex  epilepsy, 
with  caries  of  the  temporal  bone,  cured  by  an  operative  perfora- 
tion of  the  mastoid  process.  He  used  a  trephine. 

In  1870  Agnew,  at  a  meeting  of  the  American  Ophthalmo- 
logical  Society,  reported  the  case  to  which  I  have  already 
alluded.  At  the  same  meeting,  I  reported  two  cases  in  which 
I  had  opened  the  mastoid  cells  through  a  minute  fistula,  in  each 
case  with  a  stiff  probe. 

To  those  cases  was  added  a  history  of  the  operation,  which 
I  believe  was  the  first  complete  account  that  appears  in  any 
language  since  the  time  of  Berger.  In  this  paper  I  attempted  to 
lay  down  certain  indications  for  the  performance  of  the  opera- 
tion. After  seventeen  years  of  added  experience  I  do  not  know 


542  OPENING   THE   MASTOID. 

that  I  can  materially  alter  these  rules,  although  I  have  some- 
what amplified  them.' 

In  1873  A.  H.  Buck  began  his  writings  upon  the  subject  of 
opening  the  mastoid  with  a  report  of  thirty-five  cases  occurring 
in  various  parts  of  the  world,  six  of  which  are  his  own. 

In  the  same  year  Schwartze  and  Eysell a  published  an  his- 
torical account  of  opening  the  mastoid  with  a  table  of  sixty- 
three  cases,  seventeen  of  which  were  from  their  own  practice. 
This  publication  of  cases  has  continued  until  the  present  day. 

Although  it  seems  clear  to  most  writers  that  all  these  steps 
have  led  to  a  point  where  we  see  that  opening  the  mastoid  pro- 
cess in  many  cases  is  a  perfectly  justifiable  and  a  life-saving 
surgical  procedure,  the  voice  of  specialists  in  this  country  is  not 
quite  unanimous  upon  the  subject.  The  weight  of  authority 
seems  to  me,  however,  largely  in  favor  of  the  operation,  under 
the  ordinary  indications.  In  a  discussion  two  years  since,  Straw- 
bridge  3  said  that  he  had  seen  over  four  thousand  cases  of  puru- 
lent middle-ear  disease  in  the  last  twelve  years,  and  yet  he  had 
not  trephined  a  single  mastoid,  nor  had  he  seen  a  death,  except 
in  one  child,  six  months  old,  that  died  a  few  hours  after  he  first 
saw  the  case.  Dr.  Theobald  (Zoc.  cit.)  stated  that  his  experience 
accorded  with  that  of  Dr.  Strawbridge,  although  he  had  not 
seen  so  many  cases.  He  had  never  opened  the  mastoid  in  the 
living  subject.  He  had  seen  mastoid  symptoms  disappear  under 
active  constitutional  treatment.  These  experiences,  however, 
seem  to  stand  by  themselves.  Nearly  all  of  those  who  have 
seen  many  cases  of  aural  disease  have  been  obliged,  occasion- 
ally at  least,  to  open  the  mastoid.  To  me  it  seems  as  if  the 
field  of  operation  in  this  direction  were  likely  to  be  enlarged 
rather  than  diminished.  I  have  elsewhere  advised  a  thorough 
search  for  pus,  and  by  an  opening  through  the  bone  in  all  cases 
when  death  seemed  to  be  threatened  from  cerebral  abscess.  The 
only  point  in  the  subject  that  remains  open  for  discussion,  seems 
to  me  to  be  the  one  pertaining  to  cases  in  which  the  only  object 
is  to  secure  better  drainage  of  the  tympanum,  the  mastoid  itself 
being  perhaps  sound.  '  No  one  with  surgical  education  will  deny 
that  it  should  be  opened  when  there  is  pus  in  it  which  has  no  suf- 
ficient outlet.  No  one,  on  the  other  hand,  would  consent  to  open 
it  to  fulfil  such  indications  -as  those  which  deceived  poor  Berger. 

I  lay  comparatively  little  stress  upon  methods  of  operation. 
Schwartze  forsook  the  trephine  at  an  early  day  and  took  up  with 
chisels.  In  this  he  has  many  followers.  I  have  continued  to 
use  a  stiff  probe  and  a  drill  or  a  trephine.  Buck  continues  to 

1  Transactions  of  the  American  Otological  Society,  1870. 
1  Archiv  flir  Ohrenheilkunde,  neue  Folge,  Bd.,  1873. 
3  Transactions  of  the  American  Otological  Society,  1883. 


OPENING   THE   MASTOID. 


543 


use  the  drill,  occasionally  the  chisel,  while  Crosby  preferred  a 
gimlet. 

For  many  decades  aural  surgery  was  almost  exclusively  in 
the  hands  of  men  who  were  en- 
deavoring to  cure  the  incurable, 
by  injecting  vapors  and  fluids 
through  the  Eustachian  tube  in 
cases  of  chronic  non-suppurative 
inflammation  of  the  tympanum. 
Their  results  were  deplorably  bad. 
Otology  was  in  such  bad  repute 
that  no  one  would  meddle  with 
the  ear  or  investigate  its  curable 
affections. 

Sir  Astley  Cooper,  after  bene- 
fiting one  patient  by  a  paracen- 
tesis  of  the  drum-head,  although 
he  failed  in  all  subsequent  at- 
tempts, filled  his  waiting-room 
with  the  incurable  deaf,  whom  he  Fia  107a- -Wll80n's  Trephine.! 
speedily  drove  out  lest  they  should  injure  his  reputation  as  a 
surgeon.  Thus,  in  one  way  or  another,  aural  surgery  became  a 
true  terra  incognita,  about  which  the  most  absurd  tales  got 
full  audience,  and  in  which  very  few  capable  and  honest  men 
labored.  In  these  latter  and  better  days  the  light  of  scientific 
and  honest  investigation  has  so  cleared  the  pathways  in  otol- 
ogy that  even  if  one  direction  vary  here  and  there,  we  may 
walk  with  a  fearless  tread. 

So  far  as  propositions  in  regard  to  operations  upon  the  mas- 
toid  can  be  formulated,  I  should  say  : 

I.  The  integument  and  periosteum  of  the  mastoid  process 
should  be  freely  divided  in  all  cases,  when  there  is  great  pain, 
tenderness,  and  swelling  in  this  part. 

II.  Such  an  incision  should  also  be  made,  whenever  severe 
pain,  referred  to  the  middle  ear,  constantly  exists,  and  which  is 
not  even  temporarily  relieved  by  the  use  of  leeches,  poultices, 
the  warm  douche,  and  so  forth. 

III.  The  bone  should  be  thoroughly  examined  by  the  aid  of 
such  an  incision,  whenever  we  have  good  ground  for  suspecting 
that  the  bone  is  diseased  or  pus  is  retained  in  this  part. 

IV.  The  mastoid  process  should  be  perforated  after  such  an 
incision,  whenever  the  bone  is  found  softened,  and  if  a  fistulous 
opening  is  discovered,  this  should  be  enlarged.     It  should  also 
be  perforated,  when  the  suppuration  of  the  middle  ear  involves 
the  mastoid  cells  or  antrum  to  such  an  extent,  that  thorough 

1  This  new  instrument  is  a  very  safe  one,  and  easily  managed. 


544  OPENING   THE   MASTOID. 

drainage  cannot  be  secured  through  the  membrana  tympani  or 
external  auditory  canal. 

When  general  septicaemia  or  pyaemia  has  developed,  even  if 
it  has  its  starting-point  in  the  mastoid,  as  it  sometimes  does,  it 
is  of  no  use  to  chisel  or  drill  the  mastoid  process.  Purulent  in- 
fection of  the  whole  system  having  occurred,  it  is  then  too  late 
to  give  an  outlet  to  hardened  pus  at  one  point.  I  am  led  to  this 
remark,  because  I  have  seen  two  cases  in  which  the  mastoid  was 
opened,  when  the  internal  organs  were  already  the  seat  of  ab- 
scesses, the  tympanum  and  mastoid  were  dry,  and  all  hope  of 
recovery  should  have  been  abandoned.  Such  operations  only 
bring  the  procedure,  even  when  undertaken  under  proper  condi- 
tions, into  disrepute. 

I  would  not  lead  my  readers  to  think  that  I  consider  the  open- 
ing of  the  mastoid  process  as  a  trivial  procedure,  the  indications 
for  which,  need  not  be  carefully  considered  before  it  is  under- 
taken. Yet  hesitation,  when  the  way  is  plain,  or  when  the 
chances  are  largely  on  the  side  of  the  necessity  of  the  removal 
of  pus,  cannot  be  too  sternly  condemned.  No  drug  has  yet  been 
discovered,  which  can  be  substituted  for  the  scalpel,  or  trephine, 
when  pus  has  actually  formed  in  the  mastoid  cells.  I  wish,  how- 
ever, to  repeat  what  I  have  said  before  on  the  subject  of  surgical 
operations.  I  am  in  full  accord  with  the  great  English  surgeon, 
Sir  James  Paget,  who,  in  his  admirable  lectures,  expresses  many 
times  his  hesitation  to  perform  any  surgical  operation,  however 
trivial,  that  is  not  absolutely  required.  We  have  no  right,  I 
think,  to  perform  operations  to  clear  up  doubtful  diagnoses  ;  if 
in  case  the  operation  proves  to  have  been  unnecessary,  the  pa- 
tient will  be  decidedly  the  worse  for  it.  If  we  put  ourselves  in 
the  place  of  our  patients,  what  we  may  regard  as  a  trifling  thing, 
"  a  mere  cut,"  will  not  be  so  esteemed.  A  mere  cut,  when  un- 
necessary, may  have  the  most  serious  consequences,  and  all  the 
history  and  symptoms  should  be  carefully  weighed  before  even 
that  is  undertaken.  Such  care  will  never  prevent  prompt,  rapid, 
and  thorough  surgical  interference  when  demanded. 

In  teaching  medical  students,  I  have  always  found  them, 
when  fully  awakened  to  the  dangers  of  neglecting  certain  dis- 
eases, to  be  more  apt  to  do  too  much,  than  too  little,  especially 
with  the  knife  and  active  drugs.  It  is  possible  also  that  the  cry- 
ing ignorance  and  neglect  of  the  previous  decades  in  regard  to 
the  treatment  of  aural  disease,  has  had  a  tendency  to  cause  us 
who  see  many  of  the  affections  of  the  ear,  to  lean  toward  the 
side  of  surgical  operations  upon  the  drum-head  and  mastoid. 
This  is  a  leaning  no  less  dangerous  to  the  cure  of  some  cases, 
than  was  the  steering  toward  Scylla  or  Charybdis  to  the  safe 
navigation  of  ancient  mariners. 


CHAPTER  XIX. 

THE  CONSEQUENCES  OF  CHEONIC  SUPPUEATION  OF  THE  MIDDLE 
EAE— ( Concluded).—  NEUEALGIA  OF  THE  MIDDLE  EAE. 

CARIES  AND  NECROSIS  OF  THE  TEMPORAL  BONE. 

Cases. — Treatment  by  Operation  and  Internal  Medication. — Fatal  Hemorrhage. — Cere- 
bral Abscess. — Pyaemia. — Paralysis. — The  Ophthalmoscope  in  detecting  Cerebral 
Disease  of  Aural  Origin. — Neuralgia  of  the  Middle  Ear. 

THE  surgeon  is  often  baffled  in  his  efforts  to  check  a  discharge  of 
pus  from  the  ear,  because  it  conies  frorti  a  part  of  the  bone — the 
walls  of  the  tympanum — that  has  been  softened  by  a  carious  pro- 
cess. It  is  not  always  possible  to  positively  decide  that  the  bone 
is  in  this  condition,  for  the  part  thus  affected  may  be  sufficient 
to  maintain  a  suppurative  process,  and  yet  be  very  small  and 
hidden  from  view.  Even  the  proper  use  of  a  probe  in  a  diseased 
cavity  of  the  tympanum,  in  order  to  enable  us  to  decide  as  to  the 
existence  of  caries,  is  a  delicate  matter,  and  should  be  under- 
taken with  care,  lest  important  parts  be  penetrated.  The  care- 
ful surgeon  is,  therefore,  often  in  doubt  as  to  how  much  of  the 
bone  may  be  invaded,  even  when  he  finds  a  superficial  point 
that  gives  evidence  of  disease.  The  probe  cannot  be  used  in  the 
ear  as  a  diagnostic  means,  with  that  freedom  that  it  is  employed 
in  solid  parts  that  have  no  such  important  and  delicate  sur- 
roundings. 

All  parts  of  the  temporal  bone  may  become  carious  as  the 
result  of  a  chronic  suppurative  process.  The  osseous  portion  of 
the  auditory  canal  is  one  of  the  favorite  positions  for  such  a 
morbid  change.  The  upper  wall  of  this  canal  is  but  a  short  dis- 
tance from  the  dura  mater  and  the  cerebrum,  and  we  have 
already  discussed  the  relations  of  the  mastoid  cells  to  the  lateral 
sinus.  Thus  we  may  have  inflammation  of  the  brain  and  affec- 
tions of  the  venous  circulation,  even  when  the  caries  is  confined 
to  the  external  ear.  It  is  probable,  however,  that  caries  of  the 
auditory  canal  is  usually  the  result  of  a  chronic  suppuration  of 

35 


546  CARIES,  OP  TEMPORAL  BOTJE. 

the  middle  ear,  and  not  of  a  primary  and  independent  affection 
of  the  peripheral  portion.  An  exception  to  this  has  already  been 
noticed  in  one  of  the  chapters  upon  disease  of  the  auditory  canal. 
The  anatomical  relations  of  the  cavity  of  the  tympanum,  than 
which  there  are  none  more  important  in  the  whole  body,  neces- 
sarily involve  serious  consequences  from  caries  of  any  part  of 
its  walls.  These  consequences  also  necessarily  include  great 
impairment  of  the  hearing,  while  we  may  have  meningitis,  cere- 
bral abscess,  pyaemia,  paralysis,  or  fatal  hemorrhage.  Indeed, 
in  the  treatment  of  any  of  these  consequences  of  a  chronic  sup- 
puration, we  are  always  treading  upon  dangerous  ground,  which 
may  break  under  our  feet  at  any  moment.  In  some  fortunate 
cases,  however,  none  of  these  unpleasant  results,  except  the  loss 
of  hearing,  occur ;  the  diseased  bone  is  thrown  off,  and  the  parts 
heal.  Nearly  the  whole  of  the  temporal  bone  may  be  cast  off  in 
this  manner  without  involving  the  life  of  the  patient. 

It  has  already  been  seen  that  the  ossicula  auditus  may  be- 
come carious  and  lost  in  the  course  of  an  acute  suppuration. 
The  same  thing  may  occur  in  the  course  of  a  very  chronic  pro- 
cess, and  small  points  of  dead  bone  are  frequently  found  when 
the  cavity  of  the  tympanum  has  been  for  a  long  time  exposed 
from  a  loss  of  the  membrana  tympani.  It  is  shown,  however, 
from  reports  of  cases  by  myself  and  others,  that  caries  may 
occur  with  an  intact  drum-head.  Dr.  Orne  Green1  also  pub- 
lished a  report  of  a  post-mortem  examination,  that  illustrates 
the  same  fact.  Dr.  Geo.  E.  Francis,  of  Worcester,  made  the 
autopsy. 

A  man  twenty-five  years  of  age,  who  was  subject  to  catarrh, 
had  had  a  discharge  from  his  ear  for  two  years  ;  at  times  acute 
symptoms  occurred.  Two  months  before  death  he  could  not 
hear  conversation.  He  also  had  cerebral  symptoms,  dizziness, 
headache,  double  vision,  and  partial  paralysis,  but  of  what 
regions  is  unknown.  He  died  comatose,  and  at  the  autopsy  a 
collection  of  pus  was  found  in  the  brain,  just  over  a  carious  spot 
communicating  with  the  tympanic  cavity.  The  pus  lay  directly 
upon  the  bone. 

Dr.  Green  examined  the  bone,  and  found  a  sinus  through  the 
upper  osseous  wall  of  the  auditory  canal,  just  above  and  external 
to  the  small  process  of  the  malleus.  The  point  of  an  ordinary 
probe  could  be  inserted  in  this  opening,  and  it  communicated 
with  the  auditory  canal  and  the  small  cavity  in  front  of  the 
handle  of  the  malleus.  From  this  cavity  it  passed  backward 
and  inward  into  a  circular  cavity  about  one-quarter  of  an  inch 

1  Transactions  of  the  American  Otological  Society,  1871. 


NECROSIS   OF   TEMPORAL   BONE.  547 

in  diameter  in  the  cancellated  structure  of  the  bone.  The  roof 
of  bone  over  this  cavity  had  entirely  disappeared,  so  that  there 
was  a  direct  communication  with  the  brain.  All  the  walls  of 
this  space  were  irregular  and  carious.  "  The  membrana  tympani 
was  entire  and  apparently  healthy,  and  of  normal  transparency 
and  thickness  in  every  part  below  the  small  process  of  the  mal- 
leus bone." 

The  head  of  the  malleus  and  the  whole  of  the  incus  were 
wanting,  but  it  could  not  be  positively  stated,  that  they  were 
not  removed  during  the  dissection.  They  must  certainly  have 
been  in  a  softened,  diseased  condition,  or  they  would  not  have 
escaped  so  readily.  Von  Troltsch  reported  a  similar  case  to 
this,  and  called  attention  to  the  little  cavity,  which  is  a  part  of 
the  tympanic  cavity,  and  is  situated  just  above  and  external  to 
the  head  of  the  malleus.  In  a  normal  condition,  it  is  separated 
from  the  auditory  canal  by  an  extremely  thin  layer  of  bone. 
Von  Troltsch  dissected  a  specimen  in  which  he  found  a  polypoid 
growth  springing  from  this  point  and  projecting  into  the  canal. 

Dr.  O.  D.  Pomeroy '  reported  a  case  of  exfoliation  of  the  whole 
of  the  temporal  bone,  except  the  lower  part  of  the  external  audi- 
tory canal  and  the  inner  part  of  the  petrous  portion.  The  patient 
recovered,  of  course  with  loss  of  hearing  and  facial  paralysis. 
The  patient  was  a  boy  aged  twenty  months,  and  had  a  dis- 
charge from  the  ear,  accompanied  by  severe  pain  for  three 
months  before  Dr.  Pomeroy  saw  him.  There  was  mastoid  peri- 
ostitis, and  an  incision  was  made.  Two  days  after  another  was 
made,  and  the  bone  was  found  uneven  and  rough,  and  there  was 
a  fistula  leading  into  the  mastoid  cells.  For  three  months  after, 
the  child  did  moderately  well,  although  there  remained  consider- 
able swelling  in  front  of  the  auricle.  At  the  end  of  this  period, 
a  small  piece  of  dead  bone  was  observed  behind  and  a  little  above 
the  external  auditory  canal,  and  in  about  a  month  afterward  it 
became  movable,  and  was  grasped  by  forceps  and  some  traction 
was  made  upon  it,  but  so  much  hemorrhage  was  caused  that  the 
attempt  to  remove  it  was  given  up. 

Six  months  after  the  child  was  doing  well.  The  aperture 
through  which  the  sequestrum  passed  had  closed.  The  dis- 
charge of  pus  was  moderate  and  the  general  health  of  the  child 
was  good. 

Wilde, a  Agnew,3  Gruber,4  and  Voltolini 5  have  reported  cases 
of  the  extraction  through  the  external  meatus  of  the  whole  of 

1  Transactions  of  the  American  Otological  Society,  1872.          *  Text-book,  p.  37. 
3  Von  Troltsch  on  the  Ear,  American  edition.  4  Lehrbuch,  p.  542. 

6  Monatsschrif t  f iir  Ohrenheilkunde,  Jahrgang  IV. ,  p.  84. 


548  NECROSIS   OF   LABYRINTH. 

the  internal  ear,  during  the  life  of  the  patient.  Wilde's  case 
occurred  in  the  practice  of  Sir  Philip  Crampton.  The  patient 
was  a  young  lady,  who,  after  the  most  urgent  symptoms  of  in- 
flammation of  the  brain,  with  paralysis  of  the  face,  arm,  and 
leg,  and  total  loss  of  hearing  of  one  side,  recovered  from  the 
head  symptoms  and  paralysis  of  the  extremities  after  a  copious 
discharge  of  pus  from  the  ear.  "  One  day  Sir  Philip,  perceiving 
a  portion  of  loose  bone  lying  deep  in  the  cavity  of  the  meatus, 
drew  out  the  whole  of  the  cochlea  and  semi-circular  canals." 

Dr.  Agnew's  case  occurred  in  a  patient  who  suffered  from 
exostosis  consequent  upon  chronic  suppuration  of  the  opposite 
ear,  and  who  afterward  died  of  brain  disease  dependent  upon 
retention  of  pus  by  the  exostosis.  The  case  as  regards  the  ex- 
ostosis will  be  found  on  page  486  of  this  work. 

The  patient  was  a  gentleman  of  thirty-eight  years  of  age,1 
who  had  suffered  from  chronic  suppurative  inflammation  of 
the  middle  ear  for  the  greater  part  of  thirty-two  years.  Three 
years  before  the  patient  came  under  Dr.  Agnew's  observation, 
after  a  severe  exacerbation  of  the  aural  inflammation,  complete 
loss  of  hearing  occurred  in  the  ear,  and  paralysis  of  the  facial 
nerve  of  that  side.  Granulations  continued  to  recur  constantly. 
On  April  16,  1862,  the  patient  was  in  a  deplorable  condition  ;  he 
had  suffered  for  months  from  pain  in  the  ear,  loss  of  sleep,  loss 
of  appetite,  and  dizziness.  The  concha  was  swelled  and  ex- 
tremely tender ;  a  pear-shaped  polypus,  of  fibrous  character, 
which  was  kept  bathed  in  very  fetid  pus,  projected  from  the 
meatus.  Dr.  Agnew  placed  the  patient  under  the  influence  of 
chloroform,  and  removed  the  polypoid  mass  by  means  of  Wilde's 
snare.  In  attempting  to  get  the  snare  about  the  base  of  the 
polypus,  he  encountered  a  solid  body  in  the  middle  ear,  which 
proved  to  be  the  necrosed  internal  ear.  An  incision  was  then 
made  into  the  auditory  canal,  in  order  to  enable  the  forceps  to 
grasp  the  sequestrum.  Dr.  Agnew's  report  says  :  "  Having  got 
the  body  in  the  grasp  of  the  forceps,  a  slight  rocking  motion, 
with  traction,  enabled  me  to  extract  it."  The  whole  of  the  in- 
ternal ear — vestibule,  semi-circular  canal,  and  cochlea — were 
found  to  be  removed.  This  patient  lived  four  years  after  this, 
and  never  had  any  painful  symptoms  from  that  side  of  the  head 
afterward. 

Gruber's  case  occurred  in  a  child,  thirteen  years  of  age. 
Both  cochleae  were  exfoliated,  and  yet  the  patient  recovered, 
with  no  facial  paralysis — an  evidence  that  the  cavity  of  the 
tympanum  was  left  in  a  comparatively  sound  condition. 

1  American  Medical  Times,  vol.  vi.,  p.  183. 


NECROSIS    OF  TEMPORAL   BONE.  549 

Voltolini's  case  was  one  that  occurred  in  the  practice  of  Dr. 
A.  Jacobi,  of  Berlin.  The  whole  labyrinth  was  removed  from 
the  ear  of  a  child  that  is  still  living.  The  substance  of  the 
cochlea  was  not  fully  united  with  the  surrounding  bony  sub- 
stance of  the  petrous  bone,  which,  as  Voltolini  remarks,  is  evi- 
dence that  the  disease  dates  back  to  an  early  period  in  the  life 
of  the  child. 

Toynbee '  reported  four  cases  of  necrosis  of  the  cochlea  and 
vestibule,  in  which  the  parts  had  been  exfoliated  during  life. 
One  of  them  is  Wilde's  case,  already  quoted.  The  patients  were 
adults,  with  the  exception  of  one,  a  child  of  seven  years  old. 

I  also  add  to  the  literature,  the  following  case." 

A  Case  of  Acute  Inflammation  of  the  Middle  and  Internal  Ears  (Panotitis), 
Followed  by  Facial  Paralysis  and  Necrosis  and  Removal  of  the  Whole  Petrous  Por- 
tion of  the  Temporal  Bone,  with  the  Annulus  Tympanicus — Recovery. — H.  G , 

fonr  years  of  age,  female,  was  sent  to  Dr.  Roosa,  February  1,  1884,  by  Dr.  S. 
G.  Carpenter,  of  Chester,  N.  Y.,  who  furnished  the  following  history  : 

"On  June  25,  1883,  the  patient  was  attacked  with  scarlet  fever;  eruption 
was  copious  ;  temperature,  105°  F. ;  eruption  began  to  decline  on  the  sixth  day. 
The  throat  was  affected  early ;  the  tonsils,  uvula,  and  pharynx  were  covered 
with  a  dense  diphtheritic  membrane  on  the  second  day ;  the  nares  were  also 
affected,  and  discharged  an  irritating  mucus.  Soon  after  the  ears  began  dis- 
charging. Her  general  condition  was  one  of  coma,  from  which  she  could  be 
partially  aroused  by  the  handling  necessary  to  cleanse  the  throat  and  nares.  At 
the  time  that  the  eruption  began  declining,  sloughing  occurred  in  both  tonsils. 
On  the  tenth  day  facial  paralysis  was  first  noticed  on  the  left  side.  A  little 
later  a  puffy  swelling  made  its  appearance  over  the  mastoid,  which  eventually 
suppurated.  There  was  complete  deafness  for  a  time,  but  later  the  hearing 
of  the  right  ear  became  partially  restored." 

Her  condition  when  first  seen  at  the  office  was  as  follows  :  There  was  com- 
plete left  facial  paralysis  ;  discharge  from  both  ears,  that  from  the  left  being 
very  fetid  and  profuse  ;  there  was  a  fistula  in  the  mastoid  leading  down  to  rough 
bone ;  granulations  in  both  tympanic  cavities.  The  general  condition  was  good. 

February  2d. — Dr.  Roosa  made  an  incision,  under  ether,  through  the  skin 
and  periosteum  of  the  left  mastoid,  enlarged  the  existing  sinus  in  the  mastoid 
cells  with  a  drill,  and  removed  the  granulations  from  the  tympanum  with  a 
sharp  curette.  The  mastoid  cells  and  ear  were  washed  out  with  a  weak  solution 
of  chlorinated  soda,  and  a  tent  inserted  in  the  wound. 

March  13th. — The  opening  in  the  mastoid  was  enlarged,  under  ether,  and 
small  particles  of  dead  bone  scraped  off  by  Dr.  Roosa. 

March  14th. — There  is  now  an  opening  down  into  the  mastoid  cells  about 
the  size  of  the  end  of  a  little  finger.  In  dressing  the  wound  a  small  fragment 
of  bone  about  the  size  of  a  three-cent  piece  came  away.  The  patient  soon  after 
this  was  placed  in  the  Manhattan  Eye  and  Ear  Hospital,  and  from  this  time  the 
notes  were  made  by  Drs.  Beard  and  Hale,  House  Surgeons. 

1  Archiv  fur  Ohrenheilkunde,  Bd.  I.,  p.  113. 
"Archives  of  Otology,  vol.  xiv.,  No.  1,  1885. 


550 


CARIES   AND   NECROSIS. 


March  29th. — Considerable  swelling  about  mastoid  ;  the  auricle  was  pushed 
forward.  A  great  deal  of  fetid  pus  was  discharged  both  from  the  canal  and  the 
opening.  This  condition  lasted  until  April  30th,  when  loose  bone  was  dis- 
covered, and  a  piece  of  the  size  of  an  infant's  little  finger  was  removed  by  Dr. 
Roosa. 

.  On  May  29th  the  patient  was  again  placed  under  ether,  and  the  granulations 
removed  and  the  carious  mastoid  cells  gently  scraped  by  Dr.  Roosa. 

From  this  time  until  September  23d  the  wound  was  dressed  twice  daily, 
being  cleansed  with  Labarraque's  solution  by  means  of  the  syringe,  and  a  tent 
of  linen  was  pushed  well  to  the  bottom  of  the  wound.  The  discharge  was  very 
fetid  and  profuse ;  granulations  were  frequently  removed,  but  no  tendency  to 
heal  was  shown,  although  the  patient  was  in  good  health  ;  she  had  no  head 
symptoms  or  pain.  The  wound  was  dressed  with  great  difficulty  on  account  of 
the  sensitiveness  of  the  ear  to  all  handling. 

The  ophthalmoscope  showed  no  lesion  or  change  in  the  fuudus  of  either  eye. 

On  September  23d  it  was  discovered  that  a  piece  of  bone  not  only  filled  the 
entire  opening,  but  caused  tumefaction  below.  On  the  next  day  the  patient 
complained  of  pain  in  the  ear. 

September  25th.  — The  patient  was  placed  under  ether,  the  wound  enlarged 
vertically,  and  the  bone  grasped  with  dressing-forceps  and  with  slight  difficulty 
removed  by  Dr.  Emerson.  There  was  little  hemorrhage. 

It  was  found  that  the  portion  of  bone  removed  was  the  whole  of  the  petrous 
portion  of  the  temporal  bone,  photographs  of  which,  taken  of  the  actual  size, 
are  herewith  exhibited. 

For  a  few  days  after  the  operation  the  discharge  and  odor  were  greater  than 
ever,  fine  particles  of  broken-down  bone  continually  coming  away.  On  the  day 
following,  the  malleus  bone  was  washed  out  in  perfect  condition. 

On  October  14th  another  sequestrum,  which  proved  to  be  the  annulus  tympani- 
cus,  was  removed,  without  ether,  by  Dr.  Roosa.  Since  then  there  has  been  great 
and  constant  improvement.  All  discharge  and  odor  disappeared  within  a  week. 

January  20,  1885. — A  fistula  of  one  and  a  quarter  inch  in  depth  remains. 
The  discharge  from  it  is  usually  not  sufficient  to  soil  the  dressings.  The  edges 
are  contracting.  It  is  probable  that  a  permanent  but  small  fistula  will  remain. 
(See  Fig.  4.) 


FIG,  i. 


FIG.  2. 


FIG.  3. 


The  first  specimen  (Fig.  1)   is  the  entire  petrous  portion  of 
the  left  temporal  bone.     It  measures  If  inch  in  length,  f  inch 


551 


in  breadth,  and  f  inch  in  thickness.  The  posterior  surface  is 
considerably  eroded,  and  shows  near  its  centre  the  first  turn  of 
the  cochlea  (1).  Posterior  to  this  is  the  internal  auditory  canal 
(2),  i  °f  an  mck  m  depth.  At  the  lower  edge  is  the  groove  for 
the  superior  petrous  sinus  (3). 

The  anterior  surface  shows  the  eminence  for  the  superior 
semicircular  canal  in  perfect  condition  ;  anterior  to  that  the 
bone  is  eroded,  and  the  tract  of  the  facial  nerve  where  it  leaves 
the  internal  auditory  canal  and  euiters  the  tympanum  is  shown. 
The  outer  or  tympanic  surface  (Fig.  3)  shows  the  following 
objects  :  Beginning  at  the  apex,  the  bony  groove  for  the  Eusta- 
chian  tube  (1) ;  in  front  of  that,  the  promontory  (2)  ;  above  this, 
the  ovale  (3)  ;  and  below,  the  foramen  rotundum  (4) ;  above  and 
external  to  this  is  seen  aqueeductus  Fallopii  (5) ;  and  posterior, 
the  mastoid  cells  ((5). 

The  second  specimen  (Fig.  2)  is  the  annulus  tympanicus  and 
part  of  the  bony  external  auditory  canal.  The  cut  is  a  view 
of  the  internal  surface,  actual  size,  and  shows  the  groove  for  the 


FIG.  4. 

membrana  tympani  (1)  and  the  mastoid  cells  (2).  It  measures 
1^  inch  in  length,  f  inch  in  breadth,  and  i  of  an  inch  in  its  thickest 
portion. 

In  Toynbee's  cases  the  sequestra  were  not  removed  until  after 
death.  This  fact  deprives  them  of  much  of  their  importance. 
Mr.  Shaw,  of  London,  has  published  a  case  of  exfoliation  of  the 
whole  of  the  internal  ear  and  part  of  the  petrous  bone. '  As  the 
case  so  nearly  resembles  the  one  here  reported,  the  main  facts 
are  quoted : 

1  Transactions  of  the  Pathological  Society,  vol.  vii.,  London,  185& 


552  CARIES   AND   NECROSIS. 

"Boy,  seven  years  of  age,  otorrhcea  from  scarlet  fever  two  and  a  half  y ears 
ago.  Facial  paralysis  of  left  side,  and  complete  deafness.  Left  external  ear 
projected  considerably  beyond  its  proper  level ;  irregular  piece  of  bone,  sur- 
rounded with  granulations,  protruded  from  the  meatus  into  the  concha."  Mr. 
S.  "  first  extracted  the  piece  of  bone  which  projected  into  the  concha ;  this 
appeared  to  have  been  the  posterior  border  of  the  external  meatus  of  temporal 
bone.  The  cartilaginous  tube  having  been  ulcerated  by  the  pressure  of  the 
bone  fragment,  the  point  of  the  little  finger  could  be  passed  to  some  depth,  and 
another  piece  of  bone  was  felt  rolling  freely  in  the  cavity ;  this  was  removed 
with  dressing-forceps  with  some  difficulty.  Patient  made  good  recovery,  paral- 
ysis remaining.  The  bone  removed  was  nearly  the  whole  of  the  petrous  portion 
of  the  temporal  bone ;  it  measured  one  inch  in  length  and  one-half  inch  in 
thickness  and  weighed  twenty-two  grains.  On  one  side,  nearly  in  its  centre, 
was  an  opening  and  cavity,  the  internal  auditory  meatus.  Depth  of  canal  was 
three-fifths  of  an  inch,  showing  that  the  whole  of  the  internal  meatus  was  in- 
cluded. On  the  side  of  the  specimen  in  relation  to  the  brain  the  surface  pre- 
sented the  cancellated  appearance  peculiar  to  diploe,  when  it  was  concluded 
that  the  process  of  separation  had  taken  place  in  the  diploe,  and  that  the  cor- 
tical layer  had  retained  its  vitality,  and  that,  remaining  in  contact  with  the  dura 
mater,  served  as  a  barrier  to  prevent  the  disease  from  extending  to  the  cere- 
brum. The  opposite  aspect  of  the  bone  shows  the  inner  wall  of  the  tympanum, 
etc." 

Dr.  Pollak,  of  St.  Louis,  has  also  reported  a  similar  case  of 
loss  of  the  petrous  portion  of  the  temporal  bone.1 

There  was  no  diploe  in  the  case  here  reported,  and  the  bone 
showed  markings,  such  as  the  uneroded  groove  for  the  superior 
petrosal  sinus  and  the  eminence,  which  conclusively  proves  that 
it  was  separated  from  the  dura  mater  throughout  the  most,  if  not 
all,  of  its  extent. 

How  this  could  happen  without  the  meninges  becoming 
inflamed,  the  sinuses  obstructed,  and  the  internal  carotid  artery 
affected,  is  not  easily  seen. 

There  were  absolutely  no  head  symptoms,  except  the  coma 
occurring  during  the  acute  stages  of  the  scarlet  fever.  From 
this  fact,  and  the  fact  that  the  paralysis  came  on  soon  (within 
ten  days)  after  the  beginning  of  the  scarlet  fever,  we  think  we  are 
justifiable  in  thinking  that  the  internal  ear  and  petrous  bone 
were  primarily  affected  with  a  purulent  inflammation,  and  that 
it  was  not,  as  is  generally  the  case,  the  result  of  secondary  in- 
flammation extending  from  the  middle  ear. 

From  the  first  we  maintained  a  perfect  and  free  drainage  of 
the  products  of  inflammation,  both  from  the  ear  and  mastoid 
opening.  To  this  the  child  is  most  probably  indebted  for  her 
life. 

The  operative  interferences  were  only  made  when  nature. 

1  Archives  of  Otology,  vol.  x.,  p.  361. 


NECROSIS   OF  TEMPORAL  BONE.  653 

unassisted,  proved  insufficient  for  her  task  of  giving  a  free  exit 
to  purulent  and  dead  material.  The  child  took  no  drugs  during 
the  eleven  months  that  she  was  under  our  care. 


FIG.  108.  —  Left  Temporal  Bone,   from  FIG.  109.  —  Inner  Surface  6f   the  same 

Case  I.  Exterior  view,  showing  the  exter-  Specimen,  showing :  e,  The  vestibule ;  d,  d, 
nal  meatus  :  a,  Prom  which  the  anterior  wall  the  windings  of  the  cochlea,  which  have  been 
has  been  removed,  as  has  also  the  inner  wall  exposed  by  sawing  away  portion  of  the  bone; 
of  the  middle  ear;  6,  the  mastoid  process.  e,  the  tympanum,  communicating  with/,  the 

mastoid   cells,  which   have  been  exposed  by 
chipping  away  a  thin  layer  of  bone. 

The  above  engravings  illustrate  the  ravages  which  chronic 
suppuration  makes  upon  the  bony  tissue  of  the  ear.  They  were 
made  from  photographs  of  the  bones,  and  are  from  the  collection 
of  Dr.  C.  E.  Hackley,  who  kindly  allowed  this  use  of  them. 

History. — CASE  I.  (Figs.  108  and  109). — Left  temporal  bone  from  a  man  who 
had  phthisis,  and  died  suddenly  of  pneumo-thorax,  August,  1866.  His  hearing 
distance  was  nothing  for  the  watch,  nor  could  he  distinguish  words,  though  he 
seemed  to  hear  the  sound  of  the  voice.  He  was  very  much  debilitated  when  he 
entered  the  New  York  Hospital,  consequently  no  thorough  examination  was  made 
of  his  ears.  He  had  profuse  discharge  from  .both  ears,  and  polypi  on  both  sides. 
On  the  left  side,  the  post-mortem  examination  showed  polypus  attached  in  the 
middle  ear  and  extending  forward  into  the  meatus,  and  backward  into  the  mas- 
toid cells;  membrana  tympani  gone;  stapes  only  one  of  ossicles  present;  mem- 
b,rane  of  fenestra  rotunda  gone. 

CASE  II.  (Fig.  110). — Left  temporal  bone  from ,  who  entered  the  New 

York  Hospital  August,  1866,  with  great  fever  and  pain  in  the  left  ear ;  had 
been  sick  two  days.  His  disease  ran  much  the  course  of  typhoid  fever,  without 
marked  head  symptoms  other  than  the  acute  pain  in  the  ear  (which  only  existed 
the  first  few  days).  When  a  child  he  had  discharge  from  the  ear  and  post-aural 
abscess  and  disease  of  mastoid  process. 

On  the  autopsy,  pus  was  found  under  the  dura  niater  and  in  mastoid  cells  ; 


554 


NECROSIS   OF   TEMPORAL   BONE. 


the  -whole  temporal  bone  was  gone  from  the  infiltration  of  pus  through  it ;  the 
membrana  tympani  was  completely  destroyed ;  the  base  of  the  stapes  was  the 
only  part  of  the  ossicula  remaining ;  there  was  an  opening  from  the  outer  part, 
of  the  bony  meatus  upward  into  a  cavity  which  also  had  an  opening  outwardly. 


A- 


G~ 


FIQ.  110. — Left  Temporal  Bone,  sawed  through  External  Meatus,  Middle  Ear,  and  Coch- 
lea. The  pieces  are  turned  to  one  side,  showing  :  a,  Mastoid  process  ;  6,  6,  external  meatus, 
ending  in  c,  the  middle  ear  ;  at  d  there  was  an  opening  downward  through  the  bony  meatus, 
and  at  e  an  opening  upward,  by  which  there  was  a  free  communication  with  f,  the  mastoid 
cells,  which  were  separated  from  the  interior  of  the  cranium  by  a  very  thin  layer  of  bone  at 
g ;  h,  h,  show  the  cochlea  sawed  through.  (From  Dr.  Hackley's  collection.) 

CASE  V.  (Fig.  111).— August  18,  1868.— H.  O applied  at  New  York  Eye 

and  Ear  Infirmary,  on  account  of  pain  in  right  ear,  saying  he  had  a  "  kernel " 
(wax  ?)  removed  from  his  ear  two  years  previously,  by  one  of  the  surgeons  of  that 
institution.  The  right  membrana  tympani  was  found  injected,  right  Eustachian 


Flo.  111. — Right  Temporal  Bone,  from  Case  V.,  showing  the  Cranial  Surface  of  the  Bone. 
At  a  the  bone  was  very  thin,  and  broke  away  when  the  dura  mater  was  removed  ;  the  bone 
was  much  hollowed  out  about  6,  the  middle  ear.  (From  Dr.  Hackley's  collection.) 

tube  obstructed.  H.  D. — Right  ear  pressed;  Left,  ^f.  Applications  of  warm 
water,  with  occasional  leeching,  were  ordered.  After  some  time  the  walls  of 
the  meatus  swelled  so  that  the  membrana  tympani  could  not  be  seen.  Under 
varying  treatment  the  state  of  the  case  was  sometimes  better,  sometimes  worse, 
till  March,  1869.  During  his  attendance  the  patient  twice  stopped  coming, 
thinking  he  was  well,  when  he  complained  of  pain  over  the  right  side  of  the 


CARIES    OF   TEMPORAL   BONE.  555 

head,  starting  from  the  ear.  Expecting  meningitis,  he  was  taken  as  an  in-patient 
at  the  Infirmary,  April,  1869,  treated  again  with  leeches,  cold  to  head,  bromide 
of  potash,  and  tonics.  About  May  i,  1869,  he  showed  occasional  delirium,  and 
contraction  of  the  muscles  of  the  nape  of  the  neck ;  had  retention  of  urine ; 
pulse  110-130 ;  temperature  102°.  Died  May  10th.  No  discharge  from  ear  for 
thirty-six  hours  preceding  death.  On  autopsy,  twelve  hours  after  death,  we 
found  the  brain  slightly  congested ;  the  right  optic  nerve  (which  went  to  an 
atrophied  eye)  was  atrophied  both  before  and  behind  commissure  ;  the  menin- 
ges  of  the  base  of  the  cerebellum,  and  upper  part  of  the  spinal  cord,  were  cov- 
ered with  lymph  and  bathed  in  sero-pus  (about  two  oz.)  ;  right  auditory  nerve 
very  red ;  periosteum  over  the  posterior  part  of  the  right  temporal  bone  was  very 
easily  detached ;  the  bone  under  it  was  greenish,  infiltrated  with  pus ;  the  pas- 
sage from  the  middle  ear  to  the  mastoid  cells  was  much  enlarged,  with  only 
a  thin  wall  of  bone  between  it  and  the  brain.  On  detaching  the  pericranium 
this  wall  was  broken  through.  Membrana  tympani  entirely  gone  ;  the  promon- 
tory was  roughened ;  the  stapes  was  the  only  one  of  the  ossicles  left  in  posi- 
tion. 

Fig.  112,  from  a  photograph  given  me  by  Dr.  Sexton,  is  a 
view  of  the  extensive  ravages  of  diseaseof  the  temporal  bone, 
perhaps  of  a  traumatic  origin.  I  first  saw  the  case  upon  Dr. 


FIG.  112.— Caries  of  Squamotm  and  Mastoid  Portion  of  Temporal  Bone.     (From  Dr.  Sexton's 

collection.) 

Sexton's  invitation,  and  some  time  afterward,  I  was  present 
when  Dr.  George  A.  Peters,  under  whose  care  he  then  was,  per- 
formed the  operation  which  is  described  in  the  following  notes, 
kindly  furnished  me  by  Dr.  Peters. 

St.   Luke's  Hospital — Aural  Polypi— Mastoid  Disease— Dr.   Peters,   attending 
surgeon. — George  R ,  aged  forty-four,  car  driver,  native  of  the  United  States. 


556  CAEIES   OF   TEMPORAL   BONE. 

Admitted  April  13,  1876.  He  was  a  sailor  for  several  years,  and  received  a  good 
many  blows  about  the  head  at  that  time.  He  denies  any  venereal  complaint. 
Up  to  a  year  ago  he  was  perfectly  healthy  ;  at  that  time  he  had  frequent  attacks 
of  vertigo,  losing  consciousness  for  a  brief  period. 

In  June,  1875,  he  had  quite  a  large  abscess  opened  behind  the  right  ear ; 
there  was  a  free  discharge  of  pus,  and  in  due  time  it  closed.  Some  few  months 
ago  he  noticed  that  the  right  side  of  his  face  was  paralyzed.  About  this  time 
his  doctor  told  him,  that  his  right  ear  contained  polypi. 

On  admission  his  condition  is  pretty  fair.  Has  had  no  marked  attacks  of 
vertigo  for  past  few  months ;  but  his  dizziness  has  increased  and  has  become 
almost  constant,  so  that  be  has  been  unable  to  work.  Often  feels  a  desire  to 
wheel  around  and  around.  There  is  marked  paralysis  of  face  on  right  side,  and 
the  patient  imagines  there  is  loss  of  power  on  same  side,  but  examination  does 
not  seem  to  confirm  his  idea.  There  is  a  fluctuating  tumor  behind  right  ear. 

April  25th. — Exploratory  puncture  made,  and  3  ij.  of  dark  brown-colored 
serum  was  withdrawn.  Since  then  the  tumor  has  again  become  quite  tense,  and 
careful  examination  reveals  marked  pulsation.  This  impulse  is  probably  due  to 
pulsations  of  some  branches  of  posterior  auricular  artery. 

Drs.  Loring  and  Roosa  advise  the  removal  of  polypi  and  an  incision  into 
tumor. 

May  5th. — The  patient  was  etherized,  Dr.  Peters  operating.  Polypi  could  not 
be  snared,  so  they  were  evulsed.  Incision,  three  inches  long,  was  made  into  the 
tumor ;  the  incision  was  perpendicular,  and  just  over  squamous  suture  extend- 
ing down  beyond  the  mastoid  process.  No  pus  was  evacuated,  only  serum 
tinged  with  blood.  No  large  vessels  were  severed,  not  even  a  small  artery,  to 
which  a  ligature  could  be  applied,  and  yet  there  was  such  a  general  and  profuse 
oozing,  that  the  wound  had  to  be  plugged,  and  a  tight  compress  applied.  Many 
small  flat  pieces  of  bone  were  taken  away,  and  on  passing  finger  into  wound  the 
mastoid  portion  of  temporal  bone  was  found  to  be  extensively  diseased  and 
broken  down ;  so  that  the  impulse  of  the  brain  could  be  perceived  at  the  bottom 
of  the  wound.  The  amount  of  blood  lost  was  considerable. 

May  6th. — He  rallied  very  well  from  operation,  but  complains  of  extreme 
weakness.  Does  not  suffer  much  pain. 

May  7th. — Temperature  and  pulse  not  much  above  normal.  Dressing  re- 
moved, bleeding  quite  profuse.  Compress  reapplied. 

May  9th. — Compress  removed.  On  looking  into  wound,  the  entire  bottom 
of  it  (about  the  size  of  an  old-fashioned  cent)  is  seen  to  pulsate.  Finger  easily 
detects  the  pulsation,  and  here  and  there  can  perceive  pieces  of  dead  bone. 
There  is  still  considerable  oozing.  Compress  reapplied.  An  occasional  dose  of 
opium  given. 

May  10th. — He  is  stronger  and  better.  No  bleeding  on  removing  com- 
presses. Wound  washed  out  with  carbolic  water  and  dressed  with  lint  soaked 
in  carbolic  oil. 

May  15th. — He  sat  up  to-day.  Carbolic  lint  dressing  continued.  Pulsations 
still  perceptible.  Fragments  of  bone  can  be  felt  and  any  attempt  to  remove 
them  causes  bleeding. 

May  26th. — Wound  granulating  and  filling  up  rapidly.  Can  still  detect  a 
slight  pulsation  at  bottom  of  wound.  The  intense  headaches,  of  which  he  com- 
plained constantly  before  the  operation,  have  entirely  disappeared.  Discharged 
cured. 


NECROSIS   OF   TEMPORAL   BONE.  557 

The  patient  succumbed  to  the  disease  finally,  from  menin- 
gitis. 

The  history  of  the  following  case  was  given  me  by  Dr.  Cooper, 
of  New  Jersey,  together  with  the  specimen  : 

Male,  aged  sixty-five.  Gradually  increasing  bladder-disease  for  five  years. 
Enlarged  prostate.  Cystitis. 

First  part  of  December,  earache.  Severe  discharge  in  twenty-four  or  forty- 
eight  hours.  Three  years  before,  trouble  in  same  ear.  Discharge  was  less,  but 
the  ear  continued  to  trouble  him.  Pain  behind  it. 

January  5th. — Sudden  and  severe  pain  in  -head,  in  front  and  back.  Stupor 
in  twelve  hours,  and  died  January  8th,  in  morning. 

Head  opened.  Dura  mater  congested,  and  lymph  at  base  of  brain.  Abun- 
dant pus,  extending  to  the  medulla. 


FIG.  113. — Caries  of  Petrous  Portion  of  Right  Temporal  Bone  (two-thirds  size). 

Fig.  114  is  from  a  specimen  furnished  from  a  case  reported 
by  me  in  1875.1 

The  patient  was  a  man  of  twenty-five  years  of  age,  who  suf- 
fered from  suppuration  of  the  right  ear  for  four  years  or  more 
before  his  death. 

In  consultation  with  Dr.  Cameron  and  Dr.  McKay,  I  saw 
the  patient  once,  when  he  was  dying  from  purulent  infection, 
pleuro-pneumonia.  The  drum-head  was  entirely  gone,  and 
there  was  considerable  inspissated  pus  lying  in  the  tympanum. 
He  had  been  suffering  for  some  weeks  from  pain  in  his  head 
and  ear,  with  profuse  purulent  discharge.  There  was  never 
any  tenderness  over  the  mastoid.  For  several  days  his  tem- 
perature ranged  from  102°  to  103.5°.  On  May  &th  he  had  a  chill, 
and  on  the  9th  Dr.  Cameron  found  pleurisy  of  the  left  side.  On 
the  same  day  another  chill  occurred,  and  on  the  llth  pleurisy  of 
the  right  lung  was  detected,  and  double  pneumonia. 

1  Transactions  of  the  American  Otological  Society,  p.  92. 


558 


PUS    IN   LATERAL   SINUS. 


The  discharge  from  the  ear  became  more  abundant,  there 
was  copious  .expectoration,  the  head  symptoms  were  greatly 
alleviated,  the  mind  became  clear.  But  five  days  after,  chilly 
sensations  were  again  experienced  and  they  were  followed  by 
intense  pain  over  the  region  of  the  lateral  sinus.  Five  days 
after  this  I  saw  the  patient  when  he  was  unconscious,  and,  as 
has  been  said,  there  was  a  free  discharge  from  the  ear.  There 
was  also  exophthalmus.  He  died  the  next  day. 

The  post-mortem  examination  was  made  by  Drs.  Cameron, 
McKay,  Ely,  and  myself. 

Brain. — General  congestion  of  the  substance  of  the  brain 
and  very  marked  fulness  of  the  vessels  on  the  surface.  No  soft- 
ening. No  purulent  collection  ;  thrombosis  of  the  right  internal 
jugular  ;  pus  in  the  right  lateral  sinus. 

Thorax. — Suppurative  pleuritis  of  the  right  lung.     The  entire 


FIG.  114. — Caries  of  Lateral  Sinus  of  Right 
Temporal  Bone  (two-thirds  size). 


FIG.  115. — Caries  of  Squamous  Portion  of 
Temporal  Bone  (right  side,  actual  size). 


surface  of  the  lung  was  covered  with  pus.  There  was  also  pus 
in  the  right  lateral  sinus.  There  were  pus  and  serum  in  the 
pleural  sac. 

Temporal  bone. — There  was  no  trace  of  the  membrana  tym- 
pani  nor  of  the  ossicles.  The  bony  wall  of  the  right  lateral 
sinus  was  carious.  The  upper  surface  of  the  petrous  bone  was 
of  a  bluish  color.  The  cochlea  and  semi-circular  canals  were 
not  examined. 

Of  Fig.  115  I  can  furnish  no  history. 

Prognosis. — The  prognosis  of  caries  and  necrosis  of  the  tem- 
poral bone  depends  upon  several  factors.  To  a  marked  degree 
it  is  influenced  by  the  age  of  the  patient.  Young  children  will 
throw  off  quite  large  portions  of  the  bone,  and  yet  escape  with 


CARIES   AND   NECROSIS — PROGNOSIS.  559 

their  lives,  while  older  persons  will  usually  succumb  to  one  of 
the  many  consequences,  such  as  pyaemia,  hemorrhage,  abscess, 
which  may  result  from  death  of  bone  in  this  part  of  the  body. 
'The  situation  also  of  the  dead  bone  will  influence  the  prognosis 
of  caries  to  a  marked  degree.  Caries  of  the  mastoid,  especially 
"when  occurring  in  young  children,  is  very  often  recovered  from. 
Caries  and  necrosis  of  the  walls  of  the  middle  ear  is  of  course 
the  most  dangerous  of  all  that  may  occur,  especially  caries  of 
the  upper  and  lower  wall.  It  has  been  seen  that  the  whole  inter- 
nal or  labyrinth  wall  may  be  destroyed,  and  the  contents  of  the 
external  ear  be  exfoliated,  and  yet  the  patient  recover.  In 
these  cases  the  necrosed  internal  ear  seems  to  have  passed 
through  a  sound  tympanic  cavity. 

The  prognosis  of  caries  and  necrosis  of  the  temporal  bone  is, 
however,  always  grave  under  any  circumstances,  and  no  life 
can  be  said  to  be  what  the  life  insurance  companies  call  a  good 
risk,  if  a  chronic  suppurative  process  has  gone  on  to  this  extent. 
The  ossicula  auditus  may  be  thrown  off  with  comparative  im- 
punity, as  we  see  by  cases  all  about  us;  yet  even  these  cases, 
unless  the  suppuration  has  entirely  ceased,  belong  to  a  class  of 
whose  results  we  must  always  stand  in  dread.  Until  the  parts 
have  healed,  and  some  kind  of  a  neoplastic  membrana  tympani 
has  formed,  we  are  not  safe  in  giving  a  decidedly  favorable 
prognosis. 

Although  the  hearing  power  is  often  much  better  when  .the 
drum -head  is  gone  or  perforated,  than  when  it  is  present  in  a 
cicatricial  and  thickened  condition,  it  is  much  better  to  make 
every  attempt  to  restore  or  close  it.  The  presence  of  this  mem- 
brane is  essential  to  the  safety  of  the  patient  from  consequences 
much  more  serious  than  impairment  of  hearing. 

Treatment. — It  is  impossible  to  give  any  specific  rules  for 
treating  caries  and  necrosis  of  the  temporal  bone.  Each  case 
must  be  judged  by  itself,  under  the  general  rules  of  treatment 
that  have  been  given  as  appropriate  for  chronic  suppuration  ; 
the  chief  of  these  rules,  I  may  venture  to  repeat,  are  a  thorough 
removal  of  the  accumulating  pus  before  it  has  time  to  produce 
its  corroding  and  destructive  effects,  and  careful  attention  to 
the  general  health  and  habits  of  the  patient. 

It  will  often  be  necessary  to  open  the  mastoid,  and  to  cut  into 
the  bony  wall  of  the  canal  to  remove  dead  bone  that  is  obstruct- 
ing a  free  outlet  of  pus.  Those  who  will  study  the  abundant 
literature  of  operations  upon  the  diseased  temporal  bone,  will, 
I  think,  be  convinced  that  there  is  a  large  field  here  for  skilful 
.surgical  interference.  Life  has  been  saved  in  many  cases,  a 


560 


CONSTITUTIONAL   TREATMENT. 


very  long  and  tedious  suppuration  prevented  in  others,  by  the- 
timely  creation  of  a  fistula  in  the  bone,  with  the  result  of  secur- 
ing that  sine  qua  non  in  cases  of  the  constant  formation  of  pus, 
thorough  drainage. 

Of  late  the  attention  of  the  profession  has  been  called  to  the 
alleged  value  of  the  sulphide  of  calcium,  which  drug,  according 
to  Ringer,  has  "the  property  of  preventing  and  arresting  sup- 
puration "  in  cases  of  suppurations  of  the  middle  ear.  Dr.  Sexton l 
argues  earnestly,  for  the  value  of  this  drug  in  cases  of  disease  of 
the  mastoid  and  temporal  bone,  as  he  does  for  its  employment  in 
furuncular  and  external  applications.  I  am  not  at  all  convinced 
that  this  drug,  or  any  other,  has  any  such  specific  value  as  is 
claimed  for  it. 

Dr.  Theobald,*  in  a  paper  before  alluded  to  on  the  constitu- 


FIG.  116. — A  diagram  designed  to  show  the  relations  of  the  Tympanic  Cavity  to  the  Mas- 
toid Cells,  the  Jugular  Fossa,  and  the  Cavity  of  the  Cranium.  The  inner  wall  of  the  cavity 
is  exposed  to  view,  with  the  round  and  oval  windows  and  the  promontory.  M,  Mastoid  cells  ; 
J,  jugular  fossa;  E,  Eustachian  tube  ;  B,  base  of  brain.  (A  L.  Ranney.) 

tional  treatment  of  ear  disease,  thinks  the  profession  has  gone 
too  far  in  exclusively  local  treatment,  and  quotes  a  case  of  Dr. 
Buck's,  from  his  book  (p.  307)  to  support  his  views.  It  was  that 
of  a  little  girl  of  six  years  of  age,  who  had  alarming  cere- 
bral symptoms  in  connection  with  a  severe  attack  of  acute  in- 
flammation of  the  drum  of  each  ear.  The  membranes  of  the 
drum  were  red  and  bulging.  A  free  incision  was  made.  On  the 
following  day  the  child  was  in  a  state  of  partial  coma;  pulse 
140.  Upon  the  advice  of  consulting  surgeons  mercury  was  given 
internally  and  externally  (calomel  and  inunctions  of  the  oleate 
of  mercury),  as  well  as  bromide  of  potassium.  An  active  dis- 

1  The  Treatment  of  Diseases  of  the  Middle  Ear  and  Contiguous  Parts  "by  Milder 
Measures  than  those  Commonly  in  Vogue.     Medical  Record,  vol.  xxi.,  No.  3,  p.  57. 

2  Chapter  XIV.,  his  book. 


CONSTITUTIONAL   TREATMENT.  561 

charge  established  itself  during  the  night,  and  the  child  made  a 
rapid  recovery.  Dr.  Theobald  believes  that  the  change  in  this 
case  was  due  to  the  mercury,  but  I  think  we  have  all  seen  just 
such  changes  occur  where  no  drug  was  used,  but  when  the  sup- 
puration was  encouraged  by  poultices,  and  the  warm  douche,  or 
even  when  nothing  was  done.  Dr.  Theobald  is  an  earnest  advo- 
cate for  the  use  of  mercury  in  aural  disease,  and  quotes  with  ap- 
proval Sir  William  Wilde,  who  valued  the  bichloride  of  mercury 
so  highly  in  acute  and  chronic  aural  disease.  I  have  given  mer- 
cury a  fair  trial  in  public  and  private  practice,  and  as  I  have 
already  said  in  this  book,  I  shall  probably  never  go  back  to  its 
use  except  as  a  tonic,  in  persons  who  have  no  syphilitic  taint, 
much  as  I  value  the  experience  of  Dr.  Theobald,  who  recom- 
mends it  so  highly  in  almost  every  form  of  inflammation  of  the 
ear.  On  the  other  hand,  I  am  more  and  more  in  favor  of  the 
early  search  for  retained  pus,  so  that  if  found,  it  may  be  liberated 
in  time. 

Gruber1  mentions  one  means  of  treating  caries  of  the  tem- 
poral bone,  in  which  I  have  no  experience,  but  of  which  he  gives 
a  favorable  report,  in  some  cases  where  the  severe  pain  was  not 
relieved  by  local  antiphlogistic  and  anodyne  treatment.  This  is 
the  actual  cautery.  The  iron  is  applied  at  several  points  over 
the  mastoid  process.  After  the  bony  slough  is  removed,  an 
irritating  salve  may  be  applied  to  continue  the  counter-irrita- 
tion. Dr.  Post,  of  this  city,  also  speaks  well  of  the  actual  cautery 
as  a  less  painful  means  of  treating  mastoid  periostitis  than  the 
incision.  I  have  no  doubt,  judging  from  my  experience  in  a  case 
of  Dr.  H.  G.  Newton's — which  I  saw  in  consultation — where 
Dr.  Newton  trephined  the  mastoid  process  for  continuous  and 
severe  pain  referred  to  the  middle  ear,  but  without  finding  dead 
bone,  that  such  openings  will  do  very  much  to  relieve  the  deep- 
seated  pain  of  caries  that  is  referred  to  the  ear  and  the  brain. 

The  facilities  for  treating  chronic  suppuration,  since  we  have 
Politzer's  method  of  inflating  the  tympanum,  are  much  greater 
than  those  enjoyed  by  our  predecessors.  We  may,  by  the  em- 
ployment of  this  method,  more  thoroughly  cleanse  the  tympanic 
cavity  from  pus  than  by  the  simple  use  of  the  syringe. 

A  patient  with  extensive  caries  of  the  temporal  bone  should 
be  made  aware  of  the  gravity  of  his  condition,  so  that  he  and 
his  friends  may  be  on  the  lookout  for  serious  symptoms,  which 
may  be  promptly  treated,  and  that  they  may  not  fall  into  the 
error  of  supposing  that  no  harm  can  possibly  come  from  "a 
simple  running  from  the  ear." 

If  polypi  or  granulations  have  occurred  in  connection  with 

1  Lelirbuch,  p.  552. 
36 


562  FATAL   HEMORRHAGE   FROX   CARIES. 

caries  of  the  canal  or  tympanic  cavity,  they  should  be  removed 
with  care,  lest  severe  hemorrhage  occur,  or  other  harm  to  the 
parts.  The  galvano-cautery  has  proved  an  efficient  and  safe 
means  of  removing  such  granulations,1  and  of  causing  the  bone 
to  heal. 

Fatal  hemorrhage  has  occurred  from  caries  of  the  bony 
canal,  in  which  the  internal  carotid  passes  through  the  apex 
of  the  petrous  portion  of  the  temporal  bone,  as  well  as  from 
destruction  of  the  bony  wall  that  separates  the  mastoid  process 
from  the  lateral  sinus,  and  also  from  the  breaking  down  of  the 
thin  plate  of  bone  that  forms  the  floor  of  the  cavity  and  sepa- 
rates it  from  the  jugular  vein.  Fortunately  for  the  lives  of 
many  patients,  there  is  a  tendency  to  thickening,  or  hyperplasia 
of  the  bony  walls  of  the  tympanum,  in  some  cases,  and  thus 
they  are  protected  from  the  corroding  effects  of  pus.2 

Hessler 8  has  recently  collected  nineteen  cases  of  hemorrhage 
from  the  internal  carotid,  in  consequence  of  caries  of  the  tem- 
poral bone.  One  of  these  is  Billroth's  case,  here  quoted  from 
Gruber.  A  case  in  Hessler's  own  practice  led  him  to  look  up 
the  literature  of  the  subject,  which  he  found  uncollected.  This 
was  that  of  a  woman,  who  died  suddenly,  while  suffering  from 
caries  of  each  tympanum,  from  an  enormous  hemorrhage  from 
the  mouth,  nose,  and  right  ear.  In  thirteen  of  the  cases  col- 
lected by  Hessler  the  diagnosis  was  rendered  certain  by  a  post- 
mortem examination.  One  of  these  was  his  own.  In  the  six 
remaining  cases,  although  a  necroscopy  was  not  had,  it  is  prob- 
able that  death  resulted  from  hemorrhage  of  the  carotid. 

He  closes  his  valuable  article  with  an  account  of  three  cases, 
in  which  the  section  after  death  revealed  complete  absence  of 
the  osseous  canal  of  the  carotid,  and  although  this  canal  had 
been  surrounded  by  pus,  no  hemorrhage  had  occurred. 

The  first  case  quoted  by  Hessler  is  from  Boinet  (Archiv  gen. 
de  Med.,  xiv.,  1837).  The  patient, had  suffered  for  seven  years 
from  chronic  suppuration.  He  had  then  severe  hemorrhages  in 
two  days  and  died.  The  second  is  from  Chassaignac's  treatise 


1  Archiv  ftir  Ohrenheilkunde,  Bd.  VI.,  p.  116. 

2  Gruber :  Lehrbuch,  p.  543.     Gruber  states  that  Billroth  has  tied  the  common 
carotid  artery  for  a  case  of  aural  hemorrhage,  which  occurred  not  from  caries,  but 
from  a  congenital  defect  in  the  bony  wall.     The  hemorrhage  ceased  for  ten  days  after. 
After  all  attempts  to  restrain  the  hemorrhage  were  fruitless,  Billroth  ligated  the  left 
carotid,  and  two  days  after  the  patient  died  from  severe  hemorrhage  from  the  right 
ear,  the  nose,  and  mouth.     A  child,  for  whom  parents  would  not  allow  the  operation, 
died  from  the  same  cause.     Koeppe  reports  a  case  of  hemorrhage  from  the  lateral 
sinus,  through  the  nose  and  ear.     This  was  in  consequence  of  destruction  of  the  bone. 

1  Archiv  fur  Ohreuheilkuude,  Bd.  XVIII. ,  p.  1  et  seq. 


FATAL   HEMORRHAGE   FROM    CARIES.  563 

on  "Suppuration,"  I.,  page  529.  He  had  suffered  from  aural 
disease  for  six  months,  suppuration  and  facial  paralysis  for  six 
weeks.  He  also  had  tuberculosis  of  the  lungs.  He  had  three 
hemorrhages  in  three  days  and  died.  Plugging  the  external 
auditory  canal  only  caused  the  blood  to  run  out  through  the 
Eustachian  tube.  Two  cases  are  quoted  from  Toynbee.  In  one 
of  his  cases,  the  patient  also  had  phthisis  pulmonalis.  The  fifth 
case  is  from  Baizeau  (Gaz.  d.  Hop.,  page  88.  1861).  Here  also 
was  phthisis.  The  patient  was  a  soldier,  twenty-three  years  of 
age.  For  ten  months  he  had  had  chronic  suppuration  of  the 
ear.  The  hemorrhage  occurred  after  coughing.  The  common 
carotid  was  tied,  but  the  bleeding  recurred  and  the  patient  died. 
In  the  sixth  case,  from  Choyan,  there  is  no  mention  of  disease 
of  the  lungs.  There  were  three  hemorrhages,  in  a  patient  who 
had  suffered  for  several  months  from  chronic  suppuration  (Ar- 
chiv  gen.  de  Med.,  May,  1866).  Broca,  in  1866,  reported  a  case 
of  tuberculosis  of  the  lungs,  caries  of  the  temporal  bone,  with 
several  hemorrhages.  The  hemorrhage  was  stopped  by  ligation 
of  the  common  carotid,  but  the  patient  died  soon  after  from 
tuberculosis. 

The  remainder  of  this  series  of  cases  also  tend  to  show,  that 
fatal  hemorrhage,  from  caries  of  the  bony  surroundings  of  the 
carotid  artery,  is  especially  apt  to  occur  in  phthisical  patients. 
In  one  case,  that  of  Piltz,  the  patient  was  syphilitic.  His  lungs 
were  sound.  The  carotid  was  tied  in  three  of  the  nineteen  cases. 
In  none  of  the  cases,  however,  was  the  hemorrhage  permanently 
arrested,  but  in  one  case  death  did  not  occur  for  two  months  and 
a  half.  The  time  from  the  first  hemorrhage  until  death  varied 
from  five  minutes  to  thirteen  days  in  those  cases,  in  which  the 
carotid  was  not  tied.  In  two  of  the  cases  in  which  the  carotid 
was  tied,  death  occurred  in  twenty  and  twenty-four  days  respec- 
tively. Thus  far,  no  essential  results  have  been  obtained  from 
treatment,  either  by  the  tampon,  digital  compression,  or  ligation 
of  the  carotid.  The  nature  of  the  disease,  forbids  any  but  a  bad 
prognosis.  When  the  bleeding  is  not  from  the  carotid  but  from 
the  tympanum,  or  a  polypus  springing  from  this  part,  the  prog- 
nosis is  generally  good.  Thorough  plugging  the  bottom  of  the 
canal,  with  the  use  of  persulphate  of  iron,  will  generally  arrest 
the  hemorrhage,  but  here  we  are  not  dealing  with  a  large  vessel. 

CEREBRAL  ABSCESS. 

The  proceedings  of  pathological  societies  and  surgical  rec- 
ords show,  that  abscess  of  the  cerebrum  more  frequently  results 
from  disease  of  the  middle  ear  than  from  any  other  single  cause. 


564  CEREBRAL   ABSCESS. 

Of  seventy-six  cases  of  cerebral  abscess  collected  by  Drs.  Gull 
and  Button,1  twenty-five,  or  about  one-third,  were  directly  trace- 
able to  chronic  suppurative  processes  in  the  middle  ear.  Le- 
bert,"  in  his  article  upon  this  subject,  considers  that  aural  dis- 
ease is  the  cause  of  cerebral  abscess  in  about  one-fourth  of  the 
published  cases. 

Toynbee's  catalogue  contains  ten  cases  of  cerebral  abscess 
from  aural  disease. 

There  is  usually  caries  in  connection  with  the  cerebral  ab- 
scess, but  cases  have  occurred  in  which,  although  the  disease 
of  the  ear  extended  to  the  brain,  there  was  no  death  of  bone. 
The  anatomy  of  the  cavity  of  the  tympanum,  especially  of  the 
roof,  or  tegmen  tympani,  where  a  process  of  dura  mater  actu- 
ally extends  into  the  tympanic  cavity,  and  where  there  may 
normally  be  a  gap  in  the  bone,  has  taught  us  how  easily  this 
may  occur.  The  cause  of  the  extension  of  a  suppurative  pro- 
cess to  the  brain  is  undoubtedly  very  often  that  which  Mr. 
Toynbee  so  clearly  sets  forth  in  his  chapter  on  this  subject — 
that  is,  the  non-escape  of  the  pus  externally  through  the  mem- 
brana  tympani.  The  perforation  of  the  membrana  tympani  in 
acute  inflammation  usually  prevents  any  such  disaster  as  the 
passage  of  the  pus  to  the  brain  or  the  circulation. 

Rupture  of  the  membrana  tympani  is,  therefore,  a  conserva- 
tive process,  if  suppuration  has  once  been  established  ;  for  there 
is  no  other  safe  way  of  escape  for  the  pus,  except  through  the 
Eustachian  tube — a  means  of  exit  which  is  one  of  the  last  that 
nature  chooses.  Abscess  of  the  brain  in  acute  disease  was  only 
once  observed  by  Mr.  Toynbee,  but  it  has  since  been  observed 
by  myself. 

A  direct  communication  usually  takes  place  between  the 
diseased  mastoid  or  petrous  portion  of  the  temporal  bone  and 
the  brain  substance  through  the  meninges,  but  the  dura  mater 
and  other  membranes  may  be  healthy,  and  even  a  portion  of 
healthy  brain  may  lie  between  the  diseased  bone  and  the  cere- 
bral, abscess.  The  chronic  disease  of  the  ear  may  be  going  on 
very  well,  until  some  mechanical  injury — exposure  to  cold,  or 
the  like — sets  up  an  acute  process,  which  extends  to  the  brain 
through  the  delicate  bony  walls  of  the  tympanic  cavity,  or  the 
cancellous  structure  of  the  mastoid  bone. 

Patients  suffering  from  chronic  suppuration  of  the  middle 
ear  cannot  be  too  much  guarded  against  blows  or  falls  upon  the 
ear,  or  against  exposures  to  sudden  changes  of  temperature, 

1  Reynolds'  System  of  Medicine,  vol.  ii. ,  p.  544. 
*  Virchow's  Archiv,  Bd.  X.,  p.  391. 


CEREBRAL   ABSCESS.  565 

draughts  of  air,  or  the  like;  for  the  histories  of  many  cases 
show  that  meningitis,  cerebral  abscess,  and  pyaemia  may,  from 
such  exciting  causes,  be  the  determination  of  a  purulent  dis- 
charge from  the  ear. 

The  symptoms  of  disease  of  the  brain  are  sometimes  very 
insidious.  At  times  there  is  a  chill  or  a  convulsion,  or  nausea 
and  vomiting ;  at  others,  only  increased  pain  in  the  ear,  fol- 
lowed in  rapid  order  by  paralysis,  coma,  and  death.  In  very 
rare  cases  there  are  absolutely  no  symptoms,  except  those  of  a 
chronic  suppurative  process  in  the  ear,  until  death  occurs. 

The  table  of  fatal  cases  of  aural  disease  resulting  from 
chronic  suppurative  processes,  added  to  this  chapter,  was  com- 
piled from  various  sources,  in  order  to  show  the  variable  char- 
acter of  brain  symptoms  supervening  an  otitis  media  purulenta, 
and  the  anxiety  with  which  such  a  case,  especially  if  united 
with  caries  on  necrosis  of  bone,  should  be  regarded. 

It  is  interesting  to  note  how  slowly  the  profession  came  to 
recognize  the  fact  that  when  pus  was  found  in  the  brain  com- 
municating with  the  ear,  that  it  was  on  its  way  inward,  and 
not  making  an  external  opening.  It  seems  to  have  been  hard 
for  the  medical  men  of  a  few  generations  back,  to  believe  that 
aural  disease  could  cause  any  serious  affection,  or  that  it  was  a 
matter  of  much  account,  although  people  were  dying  all  about 
them  from  the  results  of  aural  disease  alone.  Lebert '  says  that 
Morgagni,  "with  his  good  tact  and  close  observation  of  Nature," 
discovered  that  the  ear  was  often  the  cause  of  purulent  affec- 
tions of  the  circulation  and  brain  substance;  but  Itard  took  a 
step  backward,  and  discovered  a  kind  of  cerebral  abscess  which 
broke  out  through  the  ear.  Lallemand  again  placed  the  subject 
in  its  right  light,  and  showed,  what  we  now  clearly  see,  in  cases 
of  cerebral  abscesses  occurring  in  connection  with  suppuration 
of  the  ear,  that  the  organ  of  hearing  was  the  part  first  affected. 

It  is  generally  believed  that  a  suppurative  process  in  the  ear 
is  necessary  for  the  production  of  an  abscess  of  the  brain,  and 
this  is  probably  the  fact ;  but  one  case  that  I  observed,  leads  me 
to  suspect  that  there  may  be  such  a  thing  as  a  chronic  cerebral 
abscess  leading  to  disturbing  aural  symptoms,  such  as  tinnitus 
aurium  and  pain  in  one  side  of  the  head,  without  any  primary 
aural  affection.  I  treated  a  gentleman  of  about  twenty-nine 
years  of  age,  for  some  months,  for  such  symptoms  as  have  been 
indicated,  and  when  he  died  a  cerebral  abscess  was  found.  He 
could  hear  the  watch  only  three  inches  from  the  left  ear,  which 
•was  the  affected  one,  and  the  drum  membrane  was  sunken.  I 


1  Virchow's  Archiv,  Bd.  IX.,  p.  382. 


566  CEREBRAL    ABSCESS. 

supposed  the  case  to  be  one  of  chronic  proliferous  inflammation 
of  the  middle  ear.  The  patient  got  no  relief ;  he  became  very 
despondent  on  account  of  his  tinnitus  aurium  and  pain,  gave  up 
his  business,  and  died  at  Sag  Harbor,  L.  I.,  of  malignant  pus- 
tule, about  two  years  and  a  half  after  I  first  saw  him,  and  three 
years  and  a  half  after  his  first  aural  symptoms.  Dr.  George  A. 
Sterling,  of  that  place,  made  a  post-mortem  examination.  He 
found  "great  injection  of  the  pia  mater  over  petrous  portion  of 
temporal  bone,  and  an  abscess  about  the  size  of  a  ten-cent  piece 
in  the  brain  substance.  It  was  bounded  by  inflammatory  adhe- 
sions, and  contained  about  ten  drops  of  pus.  The  abscess  was 
situated  on  the  left  side,  in  the  superior  lobe,  one  inch  from  the 
median  line  and  two  inches  from  the  coronal  suture."  This  pa- 
tient never  had  a  suppurative  inflammation  in  the  ear,  and  it 
is  possible  that  the  cerebral  abscess  was  the  cause  of  his  very 
distressing  symptoms,  although  the  data  are  not  full  enough  to 
allow  us  to  give  a  positive  opinion.  There  is  no  account  of  an 
examination  of  the  temporal  bone. 

Through  the  labors  chiefly  of  Macewen,  of  Glasgow,  great 
advances  have  been  made  in  the  diagnosis  of  cerebral  abscess 
resulting  from  aural  disease.  What  is  much  more  important, 
lives  have  been  saved  by  timely  interference.  The  danger  of 
exposing  and  cutting  into  the  brain  was  formerly  considered  as 
very  great,  but  surgical  experience  has  shown  this  to  be  greatly 
exaggerated,  and  no  aural  surgeon  should  now  hesitate  to  tre- 
phine the  skull  in  the  spheno-temporal  fossa,  in  a  case  where 
there  is  reasonable  grounds  for  believing  that  we  may  have 
cerebral  abscess.  I  have  great  satisfaction  in  noting  that  what 
was  said  upon  page  553  of  the  last  edition  of  this  work  was 
prophetic.  It  was  then  said  that  "  surgery  has  certainly  some- 
thing to  hope  for  in  the  more  careful  search  for  pus  beneath  the 
skull."  Operations  for  cerebral  abscess  are  now  well  established 
among  the  legitimate  and  necessary  procedures  in  surgery. 
Personally  I  have  operated  but  once  as  yet,  and  then  without 
success,  but  cases  are  being  constantly  reported  *  where  a  suc- 
cessful result  has  been  obtained.  One  of  the  late  ones  will  be 
found  in  a  paper  by  Dr.  Pritchard  *  of  London. 

PYAEMIA. 

It  is  well  known  that  pyaemia,  or  metastatic  abscesses  (sep- 
ticaemia), from  the  entrance  of  pus  into  the  circulation  through 
the  mastoid  veins  or  the  lateral  sinus,  may  result  from  aural 


1  Archives  of  Otology,  vol.          p. 

*  Transactions  International  Congress  of  Otology,  Brussels,  1888. 


PYAEMIA.  567 

disease.  A  case  of  the  late  Dr.  Ely  and  myself,  which  resulted 
in  recovery,  is  an  interesting  one.  It  has  already  been  pub- 
lished/ but  chiefly  with  the  view  of  pointing  out  the  interest- 
ing fact,  that  the  recovery  occurred  without  the  use  of  medicine. 
It  is  important  enough  to  be  inserted  in  this  connection,  for  it 
illustrates  more  than  one  point  in  aural  practice.  I  quote  from 
Dr.  Ely's  account  of  the  case  : 

Chronic  Suppuration  of  both  Middle  Ears — Mastoid  Periostitis — Wilde's  Inci- 
sion—  Opening   of  Cells   by   a   Probe — Relief  for  Seven  Days — Chill — Pyaemia — 

Recovery. — Louis  S ,  aged  fifteen,  has   had  chronic  suppuration  of  both 

middle  ears  for  many  years.  During  the  past  year  he  has  been  treated  in  the 
clinic  of  Dr.  Roosa  and  myself  at  the  Manhattan  Eye  and  Ear  Hospital,  and 
nothing  unusual  has  been  observed  about  his  case  until  lately.  On  the  after- 
noon of  January  20th  he  \vas  brought  to  me  with  well-marked  mastoid  periostitis 
on  the  right  side.  The  cause  of  this  inflammation  was  not  evident.  The  red- 
ness, tenderness,  and  swelling  were  confined  chiefly  to  the  anterior  two -thirds  of 
the  mastoid  process,  and  the  swelling  was  not  very  great.  There  was  severe 
pain  in  that  side  of  the  head,  and  marked  constitutional  disturbance.  An  im- 
mediate operation  was  advised,  but  was  declined  by  the  family.  The  boy  was 
taken  into  the  hospital,  however,  and  four  leeches  were  applied.  When  seen  by 
me  at  half-past  eight  the  next  morning,  he  was  decidedly  worse.  There  was 
high  fever — a  temperature  of  104£° — and  great  pain  in  the  right  side  of  the  head. 
With  the  assistance  of  the  house-surgeon,  Dr.  Cox,  I  made  a  Wilde's  incision,  but 
found  no  pus.  The  bone  exposed  by  the  incision  seemed  sound  ;  but  after  con- 
siderable burrowing  under  the  anterior  flap  of  the  wound,  I  detected  a  softened 
spot  in  the  bone  through  which  a  stiff  probe  was  gradually  worked  into  the 
mastoid  cells,  and  a  small  quantity  of  thick  pus  then  escaped.  After  the  fistula 
had  been  enlarged,  a  tent  was  inserted,  a  poultice  applied,  and  the  hot  douche 
ordered  to  be  used  every  two  hours.  The  operation  was  performed  under  ether. 
The  bad  symptoms  were  immediately  relieved.  At  1  P.M.  the  temperature  was 
1014°,  and  it  fell  rapidly  to  the  normal.  The  mastoid  tenderness  and  swelling 
subsided.  The  patient  seemed  to  be  making  a  speedy  recovery,  and  I  considered 
him  out  of  danger.  The  wound  was  syringed  with  carbolized  water  and  the  tent 
changed  twice  a  day ;  and  the  ear  was  douched  frequently  with  hot  water.  Ex- 
cepting that  some  pain  persisted  in  the  frontal  and  right  temporal  regions,  there 
appeared  to  be  a  progressive  improvement  in  all  respects  until  January  27th. 
Early  in  the  morning  of  that  day  he  suddenly  had  a  chill,  and  the  temperature 
at  9  A.M.  was  104^°.  He  complained  of  pains  in  various  parts  of  the  body,  espe- 
cially in  the  left  knee-joint,  the  throat,  and  along  the  right  external  jugular  vein. 
All  these  points  were  very  tender,  particularly  the  track  of  the  vein,  but  there 
was  no  external  redness  or  swelling.  The  discharge  from  the  wound  became 
less.  Between  this  date  and  February  8th  he  presented  well-marked  symptoms 
of  pyaemia.  He  had  irregular  chills  and  sweats,  and  a  temperature  varying 
irregularly  between  99i°  and  105°.  His  tongue  at  first  was  brown  and  dry,  and 
then  became  very  red,  dry,  and  glazed.  There  was  great  prostration,  a  rapid 
pulse,  and  a  dusky  pallor  of  the  skin.  There  was  marked  increase  of  the  previ- 
ous deafness  on  both  sides.  He  was  restless  at  night,  and  may  have  had  slight 

'Archives  of  Otology,  vol.  x.,  p.  41. 


568  PYAEMIA. 

delirium,  judging  from  the  account  of  his  friends  who  sat  with  him ;  but  no 
delirium  was  observed  by  any  of  his  medical  attendants.  His  pupils  always 
appeared  normal.  He  had  some  cough  and  complained  of  pains  in  his  chest,  but 
I  could  find  nothing  abnormal  by  physical  examination.  Several  copious  clay- 
colored  stools  occurred.  His  general  condition  was  so  alarming  that  I  thought 
he  would  surely  die  ;  and  this  was  the  opinion  also  of  Dr.  Koosa,  who  saw  him 
frequently  in  consultation  with  me.  An  unfavorable  prognosis  was  given  to  the 
family. 

Additional  features  of  his  sickness  may  be  gathered  from  the  following  some- 
what incomplete  notes,  which  I  made  from  time  to  time  : 

January  28th. — Pains  the  same  as  yesterday.  Pains  also  in  right  axilla,  along 
the  inner  edge  of  the  right  biceps  muscle  and  in  the  right  knee.  All  these 
points  very  tender. 

January  29th. — Discharge  from  the  wound  more  abundant,  of  dark  brown 
color,  and  fetid.  [This  continued  for  five  days.]  Pains  the  same. 

January  31st. — Pains  and  tenderness  along  each  clavicle.  A  red  and  tender 
swelling  about  the  size  of  a  walnut  has  appeared  over  the  left  sterno-clavicular 
articulation  ;  distinct  sense  of  fluctuation. 

February  2d. — Pains  and  tenderness  along  clavicles,  shoulders,  and  arms. 
Less  tenderness  along  jugular  vein. 

February  5th. — Bed  and  painful  swellings,  apparently  glandular,  in  the  neck, 
below  mastoid,  right  side.  [Deep  suppuration  occurred  in  the  tissues  of  the 
neck  subsequently,  and  the  pus  was  evacuated  through  the  mastoid  opening.] 

February  12th. — Swelling  over  clavicle  gone.  [All  who  examined  this  swell- 
ing had  diagnosticated  fluid  contents,  but  no  incision  was  made  into  it.]  Opened 
an  abscess  in  the  gum  over  the  second  molar  tooth,  right  upper  jaw,  and  evac- 
uated considerable  pus.  The  whole  right  side  of  the  face  was  flushed,  swollen, 
and  tender.  A  probe  in  the  incision  passed  about  I|  inches  upward  over  the 
exterior  of  the  bone.  "Patient  sits  up  for  the  first  time. 

There  were  no  unfavorable  symptoms  after  this  date.     The  convalescence 
was  slow,  and  the  patient  was  not  strong  enough  to  leave  his  room  until  Febru- 
ary 20th.     He  went  out  February  26th.     At  that  time  there  was  a  free  discharge 
from  the  mastoid  fistula  and  from  the  ear,  and  the  hearing  was  -fa. 
Below  is  a  partial  record  of  the  temperature  : 
January  21st.— 9  A.M.,  104^° ;  1  P.M.,  101i°  ;  7  P.M.,  10H°. 
"       22d.— 9  A.M.,  101°  ;'7r.M.,  i01°. 
"       23d.— 9  A.M.,  100°  ;  7  P.M.,  99^°. 

24th.— 9  A.M.,  99° ;  7  P.M.,  99°. 
"       25th.— 9  A.M.,  981° ;  7  P.M.,  98£°. 
"       26th.— 9  A.M.,  99° ;  7  P.M.,  98£°. 
"       27th.— 9  A.M.,  104i° ;  7  P.M.,  lOlf. 
"       28th.— 9  A.M.,  104|°  ;  12  noon,  104|° ;  7  P.M.,  103i°. 
"       29th.— 9  A.M.,  104*° ;  12  noon,  105° ;  10  P.M.,  103f  °. 
"       30th.— 9A.M.,  100J0;  2  P.M.,  103°. 
"       31st.— 9  A.M.,  100°  ;  19  P.M.,  99£°. 

From  February  1st  to  February  8th. — The  temperature  varied  between  99° 
and  101°. 

This  case  is  •  interesting  not  only  on  account  of  its  fortunate 
termination,  but  because  it  serves  to  illustrate  the  natural  course 


PYAEMIA.  569 

of  the  disease  in  question  ;  for,  throughout  his  illness,  the  patient 
took  no  drugs  whatever.  This  plan  of  treatment  was  adopted  at 
the  outset  from  my  conviction  that  no  drug  would  arrest  the 
septic  poisoning,  and  that  the  large  doses  of  quinine  often  used 
were  capable  of  doing  harm.  This  view  was  shared  by  Dr.  Roosa 
in  all  my  interviews  with  him  ;  but  it  evidently  excited  wonder 
in  the  minds  of  some  of  the  medical  visitors  who  happened  to  be 
attending  the  clinics  at  the  time.  This  very  common  feeling  of 
surprise  at  seeing  any  alarming  sickness  treated  without  the  use 
of  what  is  by  so  many  considered  essential,  shows  that  many 
minds  can  profit  by  the  study  of  just  such  a  narrative  as  has 
been  given  above. 

Aside  from  the  matter  of  drugs,  this,  boy,  of  course,  had  a 
great  deal  of  medical  treatment,  in  the  best  sense  of  the  words. 
He  had  a  quiet  room  to  himself  with  an  open  fire  ;  some  member 
of  his  family  sat  with  him  each  night,  and  he  had  the  efficient 
nursing  made  possible  through  the  kind  supervision  of  Dr.  Cox, 
as  well  as  the  latter's  constant  medical  observation.  I  visited 
him  often  myself,  and  every  small  detail  regarding  food,  stimu- 
lants, dressings,  etc.,  received  thoughtful  consideration.  For- 
tunately, food  was  well  borne  during  the  entire  period.  The 
diet  consisted  of  milk,  to  which-  was  added  a  little  sherry  wine 
at  first,  and  afterward  a  little  whiskey.  Poultices  were  kept 
applied  over  the  jugular  vein  and  upon  the  painful  swelling  over 
the  left  sterno-clavicular  joint.  The  free  action  of  the  bowels 
was  doubtless  useful  in  eliminating  the  poison,  as  has  been  re- 
marked of  other  similar  cases.  Might  not  large  doses  of  quinine 
(through  their  astringent  action)  have  tended  to  check  these 
desirable  movements  of  the  bowels,  in  addition  to  the  depressing 
effect  they  might  have  had  upon  the  nervous  system  ? 

As  soon  as  the  crisis  of  this  boy's  illness  had  passed,  the  im- 
provement in  the  expression  of  his  face  and  in  his  whole  aspect 
was  so  striking  that  it  would  naturally  have  been  attributed  to 
any  medicine  that  he  might  have  been  taking  at  the  time.  Still 
more  natural  would  such  an  inference  have  been  regarding  the 
rapid  disappearance  of  the  abscess — for  such  I  believe  it  was — 
over  the  clavicle. 

Another  interesting  point  is  that  the  sanitary  condition  of 
the  hospital  was  considered  to  be  unusually  bad  then. 

I  examined  this  patient  a  few  days  ago  (May,  1890).  There  is 
a  very  slight  purulent  discharge  from  each  tympanum,  which  is 
carefully  removed  by  the  patient  and  occasionally  by  one  of  the 
surgeons  of  our  hospital.  He  is  in  excellent  hetilth,  hears  con- 
versation, addressed  particularly  to  him,  about  two  feet  away. 


570  PYAEMIA. 

Mr.  Prescott  Hewitt,1  in  1861,  related  a  case  of  pyaemia,  and 
with  the  like  happy  result  of  recovery.  Mr.  Hewitt's  case  was  in 
substance  as  follows  :  A  young  lady,  eighteen  years  of  age,  had 
a  discharge  from  the  ear,  as  a  consequence  of  hieasles.  About 
four  weeks  after  the  occurrence  of  the  discharge  she  was  seized 
with  severe  chills,  which  were  followed  by  much  fever,  a  furred 
tongue,  and  typhoid  symptoms,  with  suppression  of  the  dis- 
charge. When  Mr.  Hewitt  saw  the  patient  the  chills  continued, 
the  skin  had  assumed  an  earthen  hue,  and  the  fever  was  intense. 
The  intellect  was  clear,  but  there  was  pain  extending  down  the 
side  of  the  neck,  along  the  course  of  the  jugular  vein,  and  the 
head  was  inclined  to  that  side.  There  was  swelling  at  the  base 
of  the  neck.  In  eight  days  pus  appeared  in  one  of  the  sterno- 
clavicular  articulations.  In  a  few  days  one  knee  became  in- 
volved, and  symptoms  of  pneumonia  appeared,  which  soon  sub- 
sided. In  about  seventeen  days  from  the  beginning  of  the 
phlebitis  swelling  and  pain  occurred  over  one  of  the  hip- joints, 
a  deep  abscess  formed,  but  it  was  opened  early,  and  the  joint  did 
not  become  involved.  The  patient  ultimately  recovered  under 
treatment  by  wine  and  morphia. 

This  case  and  the  others  reported  in  this  volume,  give  the 
clinical  features  of  purulent  infection  from  suppuration  in  the 
ear.  The  pathological  characteristics  of  the  disease  are  seen  in 
the  table  of  fatal  cases  appended  to  this  chapter.  Professor  Le- 
bert 3  has  given  us  the  fullest  account  of  the  inflammations  of 
the  sinuses  that  may  lead  to  purulent  infection. 

At  this  writing,  May,  1891,  I  have  under  my  care,  at  the  Manhattan  Eye  and 
Ear  Hospital,  a  case  of  septicaemia,  occurring  after  an  operation  upon  the  inas- 
toid,  in  which  there  was  profuse  venous  hemorrhage,  probably  from  the  mastoid 
veins.  The  patient  is  recovering.  Another  case  occurring  in  the  course  of  an 
acute  otitis  media  suppurativa,  is  also  in  the  same  hospital,  under  the  care  of 
Dr.  Emerson. 

Dr.  Hessler,8  of  Halle,  has  recently  collected  the  published 
cases  of  pyaemia  in  acute  suppuration  of  the  middle  ear.  He 
includes  but  one  of  mine,  and  that  he  doubts  somewhat.  There 
are  eight  cases  in  his  table.  The  case  of  mine  which  Hessler 
reports  is  that  recorded  in  discussing  the  nasal  douche.  He  is 
inclined  to  consider  it  a  case  in  which  two  diseases  happened  to 
occur  at  the  same  time — an  acute  inflammation  of  the  middle  ear 
and  a  septic  phlegmon  of  the  left  foot.  I  am  tolerably  familiar 
with  the  symptoms  of  pyaemia,  and  although  the  case  was  origin- 
ally reported  to  show  the  harmful  results  from  the  use  of  the 
nasal  douche,  and  not  the  symptoms  of  pyaemia,  I  well  re: 
member  the  discoloration  of  the  veins  of  the  neck,  the  chills, 

1  London  Lancet,  February  2,  1861.  •  Virchow's  Archiv.,  Bd.  IX.,  p.  381. 

3  Archiv.  f iir  Ohrenheilkunde,  Bd.  XX. ,  p.  223. 


PARALYSIS.  571 

the  abscesses,  and  the  pyaemic  odor,  which  plainly  marked  this 
case  as  one  of  pyaemia,  not  only  to  me,  but  to  Dr.  Swift  and 
Dr.  Peters,  who  attended  the  case  with  me.  The  history  shows 
that  pus  found '  its  way  into  the  circulation  from  the  tympanum 
through  the  jugular  vein.  If  Dr.  Hessler  had  carefully  exam- 
ined the  Transactions  of  the  American  Otological  Society  and 
the  Archives  of  Otology  he  could  have  added  two  cases  to 
his  table  from  my  practice,  which,  whatever  my  first  case  was, 
were  typical  cases  of  pyaemia.  To  return  to  my  first  case,  how- 
ever, coincidental  phlegmonous  inflammation  of  the  foot  seems 
to  me  out  of  the  question  as  a  diagnosis,  just  as  much  as  i^ 
endocarditis,  which  another  German  authority  made  for  me,  in 
reviewing  the  case.' 

Because  it  was  not  stated  in  the  history  that  the  chest  was 
examined,  Dr.  Weber-Liel  assumed  that  an  endorcarditis  might 
have  been  overlooked,  as  does  Dr.  Hessler.  It  is  hardly  neces- 
sary to  say  that  the  patient  had  no  endocarditis,  and  that  the 
patient's  chest,  as  well  as  other  parts  of  the  body  that  are  not 
mentioned  in  the  case,  were  carefully  examined.  Hessler  ad- 
mits, however,  that,  not  having  himself  seen  my  case,  he  may 
be  mistaken  in  his  opinion  of  it. 

PARALYSIS. 

Paralysis  of  the  seventh  nerve,  as  it  passes  through  the  tym- 
panic cavity,  in  the  Fallopian  canal,  must  of  necessity  be  a 
consequence  of  many  suppurative  and  carious  affections  of  this 
part,  and  yet  it  cannot  be  said  to  be  a  frequent  affection  in  the 
course  of  chronic  suppuration  of  the.middle  ear.  In  the  greater 
number  of  the  cases  in  which  it  occurs  it  is  permanent,  from 
the  fact  that  the  nerve  tissue  is  destroyed  by  the  ulcerative  pro- 
cess ;  but  I  have  seen  several  cases  of  temporary  paralysis  of 
the  seventh,  which  were  probably  due  to  pressure  upon  the 
nerve-trunk  ;  for,  the  functions  of  the  nerve  were  finally  re- 
stored, and  the  face  resumed  its  normal  appearance. 

Paralysis  of  other  parts  of  the  body,  and  complete  hemi- 
plegia,  may  occur  in  the  course  of  meningitis  and  cerebral  ab- 
scess ;  but  these  necessary  consequences  of  the  destruction  of 
brain  substance  hardly  require  a  separate  notice. 

It  is  possible  that  a  blood-clot  might  form  between  the  dura 
mater  and  the  bone,  from  rupture  of  a  branch  of  the  middle 
meningeal,  from  caries  of  the  temporal  bone,  and  hemiplegia  be 
induced  by  pressure  communicated  to  the  motor  tract,  or,  as 
Mr.  Hutchinson  says,  as  quoted  by  Dr.  Hughlings  Jackson,3  by 
squeezing  the  blood  from  the  corpus  striatum.  or  thalamus  op- 

1  Monatsschrift  fur  Ohrenlieilkunde,  1869,  p.  180. 
*  Reynolds'  System  of  Medicine,  vol.  ii.,  p.  505. 


572  PARALYSIS. 

ticus.  The  author  has  published  two  cases  of  hemiplegia,  oc- 
curring in  coincidence  with  chronic  suppuration  of  the  middle 
ear,1  which  are  here  reproduced  as  good  illustrations  of  the  sub- 
ject, although  it  is  not  claimed  that  they  should  be  regarded  as 
positively  consequences  of  chronic  suppuration.  A  boy,  ten 
years  of  age,  was  brought  to  me  for  advice  on  May  10,  1869.  He 
had  had  a  discharge  from  the  left  ear  since  he  was  an  infant, 
and  about  four  weeks  ago  he  was  affected  with  a  number  of 
paralytic  symptoms  that  came  on  gradually.  He  became  un- 
able to  speak  distinctly,  or  to  swallow  his  food  properly,  and 
finally  he  could  not  walk  steadily.  There  was  paralysis  of  the 
seventh  pair  on  the  left  side,  and  of  the  left  arm  and  leg,  so  that 
he  could  not  grasp  well,  and  he  dragged  his  foot  in  walking. 
These  symptoms  came  on  gradually,  in  the  course  of  some 
hours,  a  fact  which  indicated  hemorrhage  between  th'e  dura 
mater  and  the  bone.  The  right  membrana  tympani  was  intact, 
but  thickened,  and  it  had  no  light  spot.  The  left  was  ulcerated 
and  perforated.  Its  remains  were  very  vascular.  His  hearing 
distance  was  ^"  from  the  right  ear,  and  -fa"  from  the  left. 
Under  the  usual  treatment  the  membrana  tympani  healed,  and 
the  hearing  power  became  normal.  The  paralysis  was  nearly 
gone  when  he  disappeared  from  observation. 

June  8,  1870. — The  patient  was  again  brought  to  me,  and 
his  mother  stated  that  he  was  seized  with  dizziness  and  loss  of 
sight  while  at  school.  He  became  so  affected  that  he  was  fif- 
teen minutes  going  two  or  three  blocks,  and  he  was  stupid  when 
he  reached  home,  although  he  had  complete  control  of  all  his 
limbs.  He  had  sight  enough  to  go  about,  but  not  to  read.  Two 
months  after  this  attack  his  vision  was  ^  with  the  right  eye,  and 
i  with  the  left.  The  field  of  vision  was  greatly  limited  on  the 
periphery.  The  ophthalmoscope  did  not  detect  any  lesion  in 
the  fundus  oculi.  Under  expectant  treatment  the  boy  slowly 
recovered  his  vision. 

The  second  case  was  that  of  a  farmer,  aged  sixty-two,  whom 
I  saw  in  October,  1869,  in  consultation  with  Dr.  Losee,  of  Red 
Hook,  N.  Y.  The  patient  had  suffered  from  chronic  suppura- 
tion of  the  right  ear,  since  he  was  a  child.  Occasionally  acute 
attacks  would  occur,  culminating  in  abscesses  of  the  mastoid. 
For  six  years  past,  the  ear  had  been  very  quiet.  About  six 
weeks  before  I  saw  the  patient,  he  was  seized  with  hemiplegia 
of  the  left  half  of  the  body,  coming  on  in  the  course  of  a  few 
hours.  When  I  saw  him  he  was  slowly  recovering  from  the 
paralysis.  The  hearing  power  on  the  right  side  was  completely 
destroyed.  The  cavity  of  the  tympani  was  exposed  and  empty. 


1  Transactions  of  the  American  Otological  Society,  1870. 


OPHTHALMOSCOPE   IN   AURAL   DISEASE.  573 

There  was  a  cartilaginous  band  extending  across  the  canal, 
which  I  divided,  and  found  that  it  contained  small  bits  of  dead 
bone,  which  seemed  to  come  from  the  posterior  wall  of  the  canal. 
The  patient  fully  recovered  from  the  paralysis,  and  is  still  living. 
Dr.  Hughlings  Jackson,1  in  lecturing  upon  epileptic,  or  epi- 
leptiform  convulsions  occurring  in  connection  with  discharges 
from  the  ear,  says,  that  arguing  from  the  fact  that  cerebral  or 
cerebellar  abscess  may  follow  disease  of  the  ear,  "it  becomes 
legitimate  to  inquire  if  minute  changes  in  tracts  of  the  brain 
may  not  occasionally  follow  a  disease  of  this  apparatus,  which 
changes  may  allow  occasional  discharge  of  nerve  force."  He  is 
anxious  to  learn  if  epileptiform  seizures  occurring  in  cases  of 
discharge  of  pus  from  the  ear,  may  not  result  from  minute 
changes  in  venous  tracts.  There  are  still  great  gaps  in  our 
knowledge  of  epilepsy  and  paralysis  dependent  upon  aural  dis- 
ease.2 Dr.  Jackson  urges  that  in  all  cases  of  hemiplegia  in  chil- 
dren the  ear  should  be  examined,  and  that  in  such  autopsies  the 
possibility  of  venous  thrombosis  from  aural  disease  should  be 
borne  in  mind. 


THE  OPHTHALMOSCOPE  AS  AN  AID   TO  DIAGNOSIS  IN  DISEASES  OF  THE 
BRAIN  RESULTING  FROM  AURAL  DISEASE. 

Dr.  Kipp 3  called  the  attention  of  the  profession  to  this  sub- 
ject. Since  then  I  am  constantly  availing  myself  of  the  assist- 
ance of  the  ophthalmoscope,  in  cases  of  chronic  suppuration 
with  serious  symptoms.  I  cannot  say  that  I  have  been  able  as 
yet  to  make  a  diagnosis  by  the  examination  of  the  entrance  to 
the  optic  nerve,  the  retina,  and  its  vessels,  that  I  did  not  make 
from  the  study  of  the  general  symptoms  and  of  the  ear,  yet  I 
think  that  a  more  general  use  of  this  assistance  in  diagnosis 
may  develop  important  results.  Whenever  we  have  a  case  of 
acute  or  chronic  suppuration  of  the  ear,  with  symptoms  of  cere- 
bral disease,  such  as  severe  pain  in  the  head,  vertigo,  nausea, 
vomiting,  or  delirium,  the  ophthalmoscope  may  be  of  service  in 
determining  whether  disease  of  the  base  of  the  brain  exists  or 
not.  That  there  is  effusion  along  the  course  or  at  the  origin  of 
the  external  muscles  of  the  eyeball  during  the  course  of  menin- 
gitis and  meningeal  hypersemia  from  aural  disease  is  well  estab- 
lished. One  such  case  is  recorded  on  page  524  of  this  book,  where 
recovery  ensued.  Dr.  Kipp  found  double  optic  neuritis  in  four 
cates  of  meningitis  from  aural  disease.  Two  of  them  recovered. 
In  the  first  case  the  optic  disks  swelled  so  much  as  to  completely 

1  British  Medical  Journal,  June  26,  1869. 

2  The  relations  of  epilepsy  to  aural  disease  will  be  discussed  somewhat  in  the  chap- 
ter upon  Diseases  of  the  Internal  Ear.  3  Archives  of  Otology,  1879,  p.  147. 


574  OPHTHALMOSCOPE   IN    AURAL   DISEASE. 

obliterate  their  margins.  The  arteries  remained  of  normal  size, 
but  the  veins  became  enlarged  and  tortuous.  There  was  also 
paresis  of  the  sixth  nerve  of  the  right  eye.  In  five  months  there 
was  no  abnormal  appearance  in  the  optic  papillae  except  that 
they  were  whiter  than  normal.  In  twenty-six  months  the  child 
was  well  as  to  her  eyes,  both  optic  disks  and  retinae  were  normal 
in  appearance,  and  vision  was  normal.  There  was  still  some 
discharge  at  intervals  from  each  ear,  and  the  drum-membranes 
were  perforated.  In  the  second  case,  which  was  a  fatal  one, 
optic  neuritis  appeared  in  ten  days  after  Dr.  Kipp  saw  the  case. 
In  this  there  was  central  caries  of  the  mastoid  cells,  abscess  of 
the  right  middle  lobe  of  the  brain,  and  thrombosis  of  the  right 
lateral  sinus.  In  the  third  case  reported  by  Dr.  Kipp  optic 
neuritis  was  found  after  the  patient  had  been  suffering  from 
acute  suppuration  with  mastoid  abscess  for  a  month.  It  may 
have  existed  long  before  this,  but  the  patient  did  not  come  under 
Dr.  Kipp's  observation  for  sometime  after  the  serious  symptoms 
appeared.  The  disks  became  very  much  swelled,  so  that  a  glass 
of  nine  inches  focal  distance  measured  the  hypermetropia  at  the 
optic  papillse,  while  at  the  maculae  the  retinae  were  of  normal 
refractive  power.  In  six  months  the  patient  was  in  excellent 
health,  without  discharge  from  the  ears,  and  the  optic  disks 
were  of  normal  color  and  flat.  The  vision  was  perfect.  In  the 
fourth  case  there  was  meningitis,  thrombosis  of  the  lateral  sinus. 
The  retinal  vessels  were  found  full  and  tortuous  two  days  after 
the  appearance  of  acute  symptoms.  The  patient  died  on  the 
eleventh  day  and  before  this  had  well-marked  optic  neuritis. 
Albutt  *  and  Wreden a  had  previously  noted  optic  neuritis  in  cere- 
bral disease  from  otitis.  Both  of  Albutt's  cases  recovered.  In 
Wreden's  case,  the  intra-cranial  disease  was  caused  by  a  neo- 
plasm originating  in  the  nasal  cavity. 

It  is  an  exceedingly  interesting  fact,  that  even  the  serious 
forms  of  optic  neuritis  seen  in  connection  with  acute  suppura- 
tion may  be  entirely  recovered  from.  No  especial  drugging  was 
resorted  to  in  these  cases,  but  the  treatment  was  pre-eminently 
local.  Had  even  small  doses  of  any  drugs  been  administered 
they  might  have  been  quoted,  in  spite  of  the  energetic  use  of  the 
knife,  poultice,  and  drainage,  as  proofs  of  the  specific  power  of 
medicines  in  arresting  suppuration. 

Dr.  J.  A.  Andrews 3  followed  up  this  subject  by  reporting  four 
cases,  in  which  optic  neuritis  was  observed  in  connection  with 
aural  suppuration.  In  one  case  recovery  occurred.  Andrews 

1  On  the  Use  of  the  Ophthalmoscope,  Appendix,  42  and43. 

5  Archives  of  Ophthalmalogy  and  Otology,  vol.  v.,  No.  1,  p.  75. 

3  Transactions  of  the  American  Otological  Society,  1883,  p.  138. 


CEREBRAL   ABSCESS.  575 

would  accept  oedema  of  the  optic  disk  in  chronic  suppurations  of 
the  middle  ear,  that  were  not  behaving  well,  as  an  indication  for 
opening  the  mastoid,  and  if  not  with  the  expectation  of  liberat- 
ing pus,  at  least  to  establish  free  drainage  from  the  middle  ear. 
Andrews  quotes  a  case  from  Zaufal  ("Inaug.  Dissertation," 
Zurich),  of  a  student,  aged  sixteen,  who  suffered  from  purulent 
otitis  media  and  optic  neuritis.  After  the  mastoid  was  opened 
the  neuritis  subsided  and  the  patient  made  a  good  recovery. 

An  interesting  discussion  followed  the  reading  of  Dr.  Andrews'  paper,  to 
which  those  specially  interested  are  referred. 

In  one  case  of  death  from  meningitis  following  acute  sup- 
puration of  the  ear,  that  came  under  my  observation,  the  post- 
mortem examination  showed  that  the  pus  might  perhaps  have 
been  reached  by  trephining  the  mastoid  process,  although  this 
part  of  the  temporal .  bone  gave  no  signs  of  disease  during  the 
progress  of  the  case,  and  an  incision  was  made  down  to  the  bone 
for  the  purposes  of  examination.  After  much  consideration  of 
these  cases,  I  am  greatly  inclined  to  advise  that  a  thorough 
search  should  be  made  for  pus,  and  by  an  opening  through  the 
bone,  in  all  cases  where  death  seems  to  be  threatened  from  a 
cerebral  abscess.  I  can  see  no  reason  why  the  surgeon  should 
sit  with  folded  arms,  when  there  is  a  certainty  on  one  side  that 
death  must  ensue  without  interference,  and  a  possibility  on  the 
other  that  the  use  of  the  trephine  might  save  life  by  the  evacua- 
tion of  an  abscess.  Surgery  certainly  has  something  to  hope  for 
in  the  more  careful  search  for  pus  beneath  the  skull.  Trephin- 
ing for  abscess  of  the  cerebrum  cannot  be  a  more  dangerous  pro- 
cedure than  when  undertaken  for  depressed  bone,  or  for  epilepsy. 
In  saying  this,  I  have  no  desire  to  retract  anything  of  what  was 
said  in  a  preceding  chapter  upon  the  performance  of  unnecessary 
surgical  operations.  Most  of  the  searches  for  the  pus  in  abscess 
of  the  brain  would  probably  result  in  failure.  I  have  myself 
failed  in  the  one  case  in  which  I  attempted  it,  but  one  success 
would  atone  for  many  failures,  for  it  would  save  a  life. 

The  table  on  the  following  pages,  which  I  have  compiled  from 
various  sources,  illustrates  in  a  striking  manner  the  fatal  con- 
sequences of  some  cases  of  aural  disease.  Taken  in  connection 
with  the  fact  already  stated, -that  suppuration  of  the  ear  is  more 
frequently  the  cause  of  cerebral  abscess  than  any  other  one  dis- 
ease, these  cases  form  a  complete  justification,  if  one  were 
needed,  for  the  giving  up  so  much  space  to  the  consequences  of 
chronic  suppuration  of  the  middle  ear.  If  the  table  shall  startle 
some  mind  hitherto  inattentive  to  this  subject,  into  a  realization 
of  its  grave  importance,  and  lead  to  a  more  careful  consideration 
of  an  ulcerated  middle  ear,  it  will  have  accomplished  its  object. 


576 


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NEURALGIA    OF   THE   MIDDLE   EAR.  583 


NEURALGIA  OF  THE  MIDDLE  EAR, 

Neuralgia  is  usually  understood  to  be  a  disease  of  the  sen- 
sory nerves,  characterized  by  paroxysmal  pain,  without  the 
objective  appearances  of  inflammation,  and  which  occurs  in  the 
course  of  nerves.  In  this  sense  neuralgia  of  the  ear  is  an  ex- 
tremely rare  disease.  Yet  it  does  sometimes  occur,  and  when 
it  does,  the  pain  is  generally  referred  to  the  tympanic  cavity 
and  the  osseous  portion  of  the  auditory  canal.  Its  origin  is 
sometimes  to  be  found  in  carious  teeth,  and  in  the  existence  of 
malarial  or  syphilitic  poisoning. 

Acute  inflammation  of  the  middle  ear,  of  a  catarrhal  or  even 
of  a  purulent  form,  was  formerly  often  mistakenly  supposed  to 
be  neuralgia.  Better  means  of  diagnosis,  and  a  consequently 
better  knowledge  of  morbid  appearances,  have  greatly  dimin- 
ished these  errors,  but  even  to  this  day  the  diagnosis  of  otalgia, 
figures  more  largely  than  it  should. 

The  supply  of  sensory  nerves  to  the  tympanum,  Eustachian 
tube  and  auditory  canal,  is  so  large,  that  it  would  be  strange  if  we 
did  not  occasionally  meet  with  a  case  of  pain  referred  to  these 
parts,  without  any  redness  of  the  drum-head  and  canal,  or  swell- 
ing of  the  tube.  Undoubtedly,  if  the  seat  of  pain  could  be  ex- 
amined in  such  cases,  the  nerve-tissue  or  its  covering  would 
show  a  pathological  condition,  either  to  the  naked  eye  or  the 
microscope,  yet  there  are  no  inflammatory  symptoms,  in  the 
ordinary  sense  of  the  term,  in  neuralgia  of  the  ear,  except  pain, 
with  perhaps  sensitiveness  of  the  canal  and  mastoid  process. 
Neuralgia  of  the  ear  may  occur  in  debilitated  and  overworked 
persons,  and  also  in  chronic  catarrhal  and  chronic  proliferous 
inflammation,  as  well  as  in  chronic  suppurations  in  anaemic 
subjects,  and  in  the  course  of  secondary  syphilis.  In  neuralgia 
of  the  middle  ear  from  diseased  teeth,  like  that  of  the  eyeball 
and  eyelids,  there  are  no  inflammatory  symptoms,  but  in  the 
earache  occurring  from  difficult  dentition,  either  the  reflex  pro- 
cess leads  very  rapidly  to  trophic  changes,  or  the  pain  in  the 
ear,  like  that  of  the  gums,  is  of  inflammatory  origin  from  the 
start.  The  continuity  of  the  mucous  membrane  of  the  mouth 
with  that  of  the  bony  Eustachian  tube  and  tympanum,  which  is 
especially  close  in  young  children,  is  sufficient  ground  for  sus- 
pecting that  the  pain  in  the  ear  in  such  subjects,  is  simply  an 
inflammation  that  has  extended  from  the  gums  to  the  middle 
ear.  Be  this  true  or  not,  and  I  believe  it  is,  infantile  earache, 
occurring  in  dentition,  is  practically  an  inflammation,  as  gener- 
ally understood,  and  not  a  neuralgia. 


684  NEURALGIA   OF   THE  MIDDLE   EAR, 

Great  importance  is  ascribed  by  certain  writers  to  the  condi- 
tion of  the  teeth  in  the  causation  of  diseases  of  the  ear.  Sexton  * 
says  that  of  fifteen  hundred  aural  cases  seen  by  him  "perhaps 
one-third  owe  their  origin  or  continuance,  in  a  greater  or  less 
degree,  to  diseases  of  the  teeth."  This  is  a  surprising  statement 
to  me,  for  on  a  careful  consideration  of  my  own  cases  of  aural 
disease,  now  reaching  in  public  and  private  practice  more  than 
ten  thousand  in  number,  I  have  notes  of  but  very  few,  not  more 
than  one  in  a  hundred,  where  it  seemed  to  me  that  the  condition 
of  the  teeth  had  any  positive  influence  in  causing  or  maintain- 
ing the  aural  disease.  The  cases  that  I  have  seen,  were  chiefly 
among  infant  children,  who  suffered  from  acute  otitis  media,  at 
the  same  time  with  an  inflammation  of  the  gums.  I  have,  how- 
ever, seen  a  few  cases  where  ulcerating  teeth  produce  what  is 
apparently  reflex  neuralgia  of  the  middle  ear.  I  have  also  in 
my  ophthalmic  practice  seen  paresis  of  accommodation  and 
keratitis  instantly  relieved,  and  ultimately  cured,  after  the  re- 
moval of  carious  teeth.  I  am  very  far  then  from  denying  that 
decaying  teeth,  or  swelled  gums,  may  produce  reflex  disturb- 
ances in  the  ear,  but  I  think  the  number  of  cases  of  aural  disease 
thus  caused  is  small.  Infantile  earache  during  dentition  is  usu- 
ally an  acute  catarrh  or  acute  suppuration  of  the  middle  ear, 
and  not  a  neuralgia.  This  inflammation  is,  I  think,  even  after  a 
consideration  of  the  theories  of  Woakes,"  caused  by  an  extension 
of  the  inflammation  of  the  mucous  membrane  of  the  mouth  and 
pharynx  to  that  of  the  Eustachian  tube.  When  a  reflex  aural 
disease  is  induced  by  the  condition  of  the  teeth,  it  is  usually  of  a 
neuralgic  and  not  inflammatory  character,  although  of  course, 
if  the  disease  of  the  nerve  or  of  its  sheath,  or  whatever  neural- 
gia may  be,  be  continued  long  enough,  changes  in  other  tissues 
may  occur. 

Dr.  C.  H.  Burnett 3  reports  the  case  of  a  physician,  who  con- 
sulted him  on  account  of  impairment  of  hearing,  tinnitus,  and  a 
peculiar  sense  of  discomfort  in  the  left  ear.  The  drum-head 
was  "lustreless,  opaque,  and  retracted."  In  a  year  neuralgia  in 
the  post-auricular  region,  with  a  constant  and  pounding  tinnitus, 
synchronous  with  the  pulse  and  a  peculiar  tapping  noise  not 
synchronous  with  the  pulse.  There  was  also  ear-cough,  but* not 
excessive.  All  of  these  symptoms  came  on  and  kept  up  during 
excessive  pain  in  the  first  molar  tooth  in  the  upper  maxilla  of 
the  same  side.  This  tooth  was  filled  ten  years  before  and  the 


1  American  Journal  of  the  Medical  Sciences,  vol.  Ixxix. ,  p.  18. 

2  Deafness,  Giddiness,  and  Noises  in  the  Head.     Second  edition,  p.  16  et  seq. 

3  The  Specialist  and  Intelligencer,  November  1,  1880. 


NEURALGIA    OF   THE   MIDDLE  EAE.  585 

aural  symptoms  had  first  shown  themselves  six  months  after 
the  tooth  was  filled.  An  abscess  finally  formed,  and  the  tooth 
was  extracted,  with  instantaneous  relief  from  all  forms  of  tinni- 
tus, tapping  sounds,  and  neuralgia  in  the  ear,  and  the  ear-cough 
and  the  hearing  became  much  better. 

Bonnafont1  devotes  considerable  space  to  neuralgia  of  the 
ear,  and  says  that  the  disease  rarely  attacks  both  ears  at  once, 
but  that  it  readily  passes  from  one  to  the  other,  in  consequence 
of  the  sympathy  between  the  two  sides  of  the  fifth  pair.  There 
is  apt,  according  to  the  same  author,  to  be  injection  of  the  con- 
junctiva and  lachrymation,  in  connection  with  otalgia. 

The  seat  of  otalgia  may  be,  according  to  Bonnafont,  in  the 
auditory  nerve,  the  chorda  tympani,  or  the  nerve-supply  of  the 
tympanic  cavity.  Bonnafont  advises  instillation  into  the  ear 
of  a  concentrated  decoction  of  poppy-heads,  and  cataplasms  or 
blisters  on  the  auricle  and  mastoid  process. 

Gruber2  reports  a  case  of  typical  otalgia  cured  by  the  use  of 
iodide  of  potassium.  Quinine  was  tried,  but  proved  of  no  service. 

Gruber  thinks  it  possible  that  there  was  an  exudation  press- 
ing upon  the  nerve  in  this  case.  The  symptoms  were  spasmodic 
contraction  of  the  left  side  of  the  head,  with  pain  in  the  ear 
occurring  at  irregular  intervals  ;  the  longest  intermissions  were 
a  few  days.  The  hearing  power  was  normal,  and  there  were  no 
pathological  objective  symptoms. 

I  have  seen  and  treated  cases  of  neuralgia  of  the  middle  ear, 
which  I  thought  to  be  of  malarial  origin.  In  one  case,  that  of  a 
physician  of  twenty-seven  years  of  age,  who  had  suffered  for 
some  months  from  acute  pain  referred  to  the  tympanum  and 
mastoid  process,  recovery  promptly  ensued  on  the  use  of  quinine. 
I  have  seen  a  few  others  in  hospital  practice,  but  I  have  no  notes 
of  the  progress  of  the  cases.  Each  case  of  neuralgia  of  the  ear 
should  be  studied  by  itself.  The  diagnosis  is  of  great  impor- 
tance, for  one  of  the  most  valuable  of  remedies  for  neuralgia, 
quinine,  is  usually  very  harmful  when  administered  in  the  course 
of  catarrh  or  suppuration  of  the  middle  ear.  Indeed  in  large 
doses,  it  is  also  harmful  in  all  the  inflammations  of  various 
parts  of  the  ear.  Its  use  should  be  avoided  in  all  persons  who 
have  hypersemia  of  the  auditory  apparatus,  or  in  those  who 
readily  suffer  from  inflammation  of  the  middle  ear.  I  have  seen 
neuralgia  in  the  ear  in  the  course  of  syphilis,  usually  as  one  of 
the  later  manifestations.  Here  of  course  the  usual  anti -syphilitic 
treatment  by  means  of  mercury  and  potash  will  be  of  service. 

1  Traite  theorique  et  pratique  des  maladies  de  1'oreille.     Paris,  1873,  p.  557. 
8  Monatsschrift  fur  Ohrenheilkunde,  Jahrgang  III.,  No.  9. 


586  NEURALGIA   OF  THE   MIDDLE   EAR. 

If  the  cause  of  neuralgia  be  once  found,  whether  it  be  a  decayed 
tooth,  the  poison  of  syphilis  or  malaria,  or  general  aneemia,  the 
treatment  will  be  simple  enough.  From  all  I  have  seen,  I  can- 
not believe  that  there  is  any  considerable  number  of  chronic 
aural  diseases  of  the  non-suppurative  variety,  that  are  in  any 
way  caused  by  the  condition  of  the  teeth.  It  is  not  very  rare, 
however,  to  find  a  neuralgic  disease  added  to  a  chronic -suppura- 
tive  process,  when  there  is  no  active  inflammation  going  on,  and 
also  in  the  course  of  the  non-suppurative  disease  of  the  same 
part.  Until  it  can  be  proven  that  people  with  sound  teeth  have 
a  particular  immunity  from  disease  of  the  ear,  it  is  hardly 
proper  to  assume  that  what  may  be  a  coincidental  condition, 
decayed  teeth — ill-fitting  and  improperly  constructed  plates  for 
false  teeth — are  actually  causes  of  any  considerable  proportion 
of  the  cases  of  chronic  aural  disease. 

I  have  carefully  examined  the  teeth  of  my  aural  patients  for 
some  years,  and  I  have  failed  to  find  that  there  was  any  strik- 
ing connection  between  chronic  disease  of  the  ear  and  bad  teeth. 
Indeed,  some  of  the  most  distressing  cases  I  have  known,  were 
in  people  with  particularly  good  teeth. 

CASES. 

The  following  case  illustrates  the  subject  of  trophic  changes 
in  the  middle  ear,  which  were  perhaps  caused  by  a  neurosis,  in 
its  turn  produced  by  dental  irritation.  The  patient  lives  in 
Italy,  and  I  have  never  learned  whether  the  diagnosis  proved 
to  be  correct. 

CASE  I. — Deafness,  Tinnitus,  Itching,  and'Pain  in  the  Left  Ear  for  Two  Years 
— Neuralgia  of  Jain  and  Face  on  same  Side,  Disease  about  and  in  Last  Molar  Tooth. 

— September  15,  1882.  Mrs. ,  aged  forty.  Has  had  deafness,  tinnitus,  pain, 

and  itching  in  left  ear  for  two  years.  Neuralgia  of  jaw,  face,  shoulder,  and  arm 
of  left  side  for  some  time.  Dizziness  and  nausea  quite  often  for  some  time  ; 
dizziness  without  nausea  before.  Has  had  a  great  deal  of  neuralgia  before,  and 
is  subject  to  headaches.  Hearing  distance,  right  ear,  }$  ;  left  ear,  IS-  Tuning- 
«.  fork  heard  on  vertex,  but  in  left  ear  (?).  Bone  conduction  better  than  aerial  on 
each  side.  The  patient  has  a  hard  swelling  high  upon  gum  above  last  molar 
tooth  of  left  side.  She  has  had  an  ulcerated  tooth  there  with  similar  swelling, 
requiring  lancing,  further  forward.  Present  swelling  increasing  in  size  ;  not 
tender.  Right  membrana  tympani  opaque  ;  fair  light  spot ;  fair  position  ;  left 
membrana  tympani  opaque  ;  fair  light  spot ;  fair  position. 

Inflation  only  felt  after  two  trials  with  chloroform.  Hearing  distance  left 
ear,  after  inflation,  i$. 

Diagnosis. — Neuralgia  and  trophic  changes  in  tympanum  from  irritation  of 
fifth  nerve. 

Advice. — Inflation,  and  advised  to  have  the  gum  and  tooth  treated. 


CASES   OF   NEURALGIA   OF  THE   MIDDLE   EAK.  587 

CASE  II. — Primary  Syphilis — Miscarriage — Nocturnal  Pains  in  the  Shin  Banes 
— Sore  Tliroat — Neuralgia  of  Tonsil,  Ear,  and  Eyeball — No  Impairment  of  Hearing 
on  the  affected  side — Sub-acute  Catarrh  of  the  Middle  Ear  on  the  other  side. — Mrs. 

O ,  aged  twenty-four,  February  21,  1884.  Patient  was  married  three  years 

since.  Three  months  after  marriage  she  miscarried,  and  soon  after  had  severe 
nocturnal  pains  referred  to  the  shins,  and  closely  following  severe  pains  in  the 
head.  Two  years  after  marriage  she  had  sore  throat.  Six  weeks  ago  she  had  a 
very  sore  throat,  and  severe  pain  referred  to  the  tonsil,  Eustachian  tube,  middle 
ear  of  the  right  side.  This  pain  continues,  although  not  constantly,  and  is  much 
worse  at  night.  The  patient  has  been  under  careful  treatment  by  mercury,  pot- 
ash, and  great  attention  to  the  nutrition  for  the  whole  time  since  the  mis- 
carriage. She  is  in  fair  condition,  but  suffers  very  much  from  the  pain  in  the 
throat  and  ear.  Her  husband  states  that  he  contracted  syphilis  two  years  before 
marriage,  but  that  he  had  no  symptoms  at  the  time  of  the  marriage.  He  had  a 
chancre,  alopecia,  papular  eruption,  and  indurated  cervical  glands.  None  of 
these  symptoms,  except  the  latter,  now  exist. 

The  hearing  distance  for  the  watch  on  the  right  side  is  about  J$.  Aerial  con- 
duction better  than  that  through  bone.  On  the  left  side  the  hearing  distance  is 
reduced  to  -4a8-,  and  the  aerial  and  bone  conduction  are  about  the  same.  There  is 
no  pain  whatever  on  this  side.  The  patient  is  not  aware  that  she  is  at  all  hard  of 
hearing.  Does  not  know  that  she  ever  had  any  earache  as  a  child.  Both  drum- 
heads are  sunken  and  opaque,  and  the  light  spots  are  small.  The  pharynx  is 
secreting  an  excessive  amount  of  muco-purulent  material.  It  is  also  swelled. 
There  has  never  been  any  dizziness  in  the  course  of  the  disease.  The  upper 
teeth  are  false.  One  of  the  molars  on  each  side  is  absent ;  the  other  teeth  are 
not  sensitive.  On  inflation  the  hearing  distance  of  the  left  ear  became  normal. 

Thanks  to  the  frankness  and  intelligence  of  the  husband  of 
ihis  patient,  I  was  enabled  to  get  a  full  history  of  the  syphilitic 
origin  of  this  case,  the  wife  being  ignorant  of  it.  My  diagnosis 
was  neuralgia  of  the  fifth  nerve  of  the  right  side,  of  syphilitic 
origin,  and  sub-acute  catarrh  of  the  left  tympanum.  It  was  a 
striking  instance  of  the  different  forms  of  disease  in  one  and 
the  same  person.  On  one  side  was  a  syphilitic,  well-marked 
neurosis,  and  on  the  other  a  syphilitic  catarrh. 

"While  preparing  these  pages  for  the  press,  Dr.  Ramsdell,  one 
£>f  the  staff  of  the  Manhattan  Eye  and  Ear  Hospital,  called  my 
attention  to  a  case  of  severe  neuralgia  of  the  middle  ear,  which 
occurred  in  the  course  of  a  chronic  suppuration  of  the  tym- 
panum. The  pain  was  decidedly  different  from  that  occurring 
from  an  increase  in  the  inflammation,  for  example,  in  mastoid 
periostitis,  being  of  an  intermittent  character.  It  was  relieved 
by  large  doses  of  opium,  and  the  inflammatory  process  made  no 
advance  while  the  neuralgia  was  under  full  headway.  A  true 
inflammation  of  the  lining  membrane  would  have  only  been  re- 
lieved by  antiphlogistic  means.  The  patient  was  an  ansemic 
woman  of  twenty-two  years  of  age. 


CHAPTER  XX. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  INTERNAL  EAR. 

The  Vestibule,  Semi-circular  Canals,  Cochlea,  and  Auditory  Nerve. — Physiology  of 

the  Internal  Ear. 

GALEN  named  the  internal  ear  the  labyrinth,  although  he  did 
not  attempt  to  describe  its  various  parts.  This  name  it  con- 
tinues to  bear,  although  so  much  labor  has  been  given  to  its 
exploration,  that  we  now  have  the  thread  to  guide  us  through 
its  devious  passages.  Yet  in  our  own  time,  a  part  of  this  in- 
ternal ear — the  cochlea — is  still  the  subject  of  vigorous  research 
and  heated  discussion,  and  different  views  are  yet  entertained 
by  competent  authorities  as  to  the  true  description  of  its  com- 
ponent parts.  I  shall  attempt  to  give  the  student  such  an  ac- 
count of  its  anatomy  as  shall  serve  as  a  basis  for  the  study  of 
its  physiology  and  diseases,  without  entering  into  the  discus- 
sion of  the  points  still  unsettled.1 

The  internal  ear  may  be  conveniently  studied  by  dividing  it 
into  the  following  parts  : 

1.  The  vestibule. 

2.  The  semi-circular  canals. 

3.  The  cochlea. 

4.  The  auditory  nerve. 

We  shall  first  study  the  osseous  envelope  of  these  parts,  and 
then  consider  their  contents ;  the  latter  being,  of  course,  far 
more  important. 

THE  VESTIBULE. 

The  vestibule  is  considered  by  all  authorities  to  be  an  essen- 
tial part  of  the  internal  ear.  A  part  answering  to  the  vestibule 
is  to  be  found  in  all  animals  in  whom  an  auditory  apparatus 
can  be  detected.  It  is  the  seat  of  the  principal  expansion  of  the 
auditory  nerve  upon  the  saccule.  This  saccule  floats  in  the  peri- 


1  In  compiling  this  anatomical  sketch,  the  text-book  of  Henle  has  formed  the  basis 
of  the  description  of  the  microscopic  anatomy  of  the  labyrinth. 


592 


THE   VESTIBULE. 


lymph,  and  communicates  through  that  fluid  with  the  membrane 
of  the  fenestra  ovalis,  and  consequently  with  the  air  in  the  tym- 
panic cavity. 

The  vestibule  is  an  irregularly  shaped  osseous  cavity,  the 
diameter  of  which  from  above  downward,  as  also  from  behind 
forward,  is  about  one-fifth  of  an  inch.  It  is  about  one-tenth  of 
an  inch  between  its  inner  and  outer  wall.  The  semi-circular 
canals  open  into  it  by  five  orifices  behind  the  cochlea,  by  a 
single  one  in  front.  The  fenestra  ovalis  is  on  its  outer  wall ; 
above  this  is  the  anterior  opening  of  the  horizontal  semi-circular 


FIG.  117.— The  Left  Vestibule,  with  the 
Semi-circular  Canals,  from  an  Adult,  seen 
from  within  (Rudinger).  1,  The  horizontal 
semi-circular  canal ;  2,  the  upper  semi-cir- 
cular canal ;  3,  the  posterior  semi-circular 
canal;  4,  a  bristle  is  passed  through  the 
aqueductus  vestibuli,  and  passes  into  the 
opening  of  two  canals,  and  appears  on  the 
upper  wall  of  the  vestibule ;  5,  the  mouths 
of  the  osseous  ampullae  of  upper  and  hori- 
zontal semi-circular  canals  ;  6,  the  opening 
of  the  lower  ampulla  of  the  posterior  semi- 
circular canal,  below  the  numbers  6  and  7 ; 
7,  the  lower  opening,  in  which  the  bristle  is 
seen,  represents  the  opening  of  the  common 
passage  for  two  semi-circular  canals. 


FIG.  118.— The  Vestibule  (after  Rudin- 
ger). 1,  The  osseous  lamina  spiralis  of  the 
cochlea,  beginning  below  and  posteriorly  on 
the  wall  of  the  vestibule ;  2,  the  scala  tym- 
pani  and  the  fenestra  rotunda ;  3,  the  scala 
vestibuli  ;  4,  fenestra  ovalis  ;  5,  the  posterior 
inferior  wall  of  the  lower  ampulla,  with  the 
inferior  macula  cribrosa,  which  serves  as  a 
passage  for  the  fibres  of  the  vestibular  nerve 
to  the  lower  ampulla ;  6,  fovea  rotunda,  or 
recessus  hemisphaericus ;  in  its  centre  are  a 
number  of  fine  openings,  the  macula  cribrosa 
media ;  through  these  the  fibres  of  the  middle 
branches  of  the  vestibular  nerve  pass  to  the 
round  saccule,  which  is  the  blind  vestibular 
end  of  the  scala  vestibuli ;  7,  the  upper  por- 
tion of  the  recessus  bemillipticus,  in  which  is 
the  upper  macula  cribrosa  ;  8,  the  lower  por- 
tion of  the  recessus  hemillipticus,  which 
passes  without  any  distinct  dividing  line  into 
the  semi-circular  canals. 


canal ;  on  its  inner  are  several  minute  holes,  making  up  the 
maculae  cribrosse  for  the  entrance  of  a  portion  of  the  auditory 
nerve  from  the  internal  auditory  canal.  At  the  posterior  part 
of  the  inner  wall  is  the  orifice  of  the  aqueductus  vestibuli,  a 
fine  canal  penetrating  the  vestibule  from  the  posterior  surface 
of  the  petrous  bone,  and  contains  a  tubular  prolongation  of  the 
lining  membrane  of  the  vestibule,  ending  in  the  cranial  cavity, 
between  the  layers  of  the  dura  mater. 

The  maculae  cribrosae  on  the  inner  wall  of  the  vestibule,  are 


VESTIBULE   AND   SEMI-CIRCULAR   CANALS.  593 

to  be  seen  with  the  naked  eye  on  the  newly  born,  but  in  the 
adult  they  are  only  to  be  seen  by  means  of  the  microscope. 
Henle  describes  four  little  groups,  each  having  five  openings, 
and  each  series  of  foramina  make  up  what  is  known  as  a  ma- 
cula cribrosa.  Through  the  macula  cribrosa  superior,  the  nerves 
pass  to  the  utricle  and  to  the  ampullae  or  flask-shaped  openings 
of  the  anterior  vertical  and  the  horizontal  semi-circular  canals. 
The  nerve -fibres  to  the  posterior  semi -circular  canals  pass 
through  the  inferior  macula  cribrosa,  and  those  to  the  saccule 
through  the  macula  cribrosa  media.  Finally,  through  the  fourth 
macula  cribrosa,  passes  the  twig  of  the  small  branch  of  the 
cochlear  nerve.  The  scala  vestibuli  of  the  cochlea  begins  on  the 
anterior  apex  of  the  vestibule. 

The  outer  wall  of  the  vestibule  is  interrupted  by  the  fenestra 
ovalis,  but  it  is  so  completely  and  smoothly  closed  by  the  base 
of  the  stapes  bone,  that  the  inner  surface  of  this  wall  of  the  ves- 
tibule appears  even.  On  the  inner  wall  are  two  depressions, 
called  respectively  the  recessus  sphsericus  and  the  recessus 
ellipticus.  A  minute  elevation  between  them  is  called  the  crista 
vestibuli. 

The  crista  vestibuli  runs  above  into  the  pyramidal  elevation 
— pyramis  vestibuli ;  below  it  divides  into  two  branches,  which 
enclose  a  space  called  recessus  cochlearis. 

Just  above  the  recessus  ellipticus  opens  the  ampulla  or  flask- 
like  orifice  of  the  anterior  vertical  semi-circular  canal.  The 
recessus  ellipticus  is  partly  bounded  below  by  a  shallow  furrow, 
sinus  subciformis.  The  two  vertical  canals  open  at  the  junction 
of  the  posterior  and  inner  wall.  On  the  same  line,  but  a  little 
higher  in  the  middle  of  the  posterior  wall,  is  the  posterior  open- 
ing of  the  horizontal  semi-circular  canal.  The  lower  opening  of 
the  posterior  vertical  canal  is  in  the  angle  formed  by  the  poste- 
rior, lower,  and  inner  wall  of  the  vestibule.  The  anterior  am- 
pulla of  the  horizontal  canal  lies  on  the  outer  wall  between  the 
fenestra  ovalis  and  the  ampulla  of  the  anterior  vertical  semi- 
circular canal. 

THE  SEMI-CIRCULAR  CANALS. 

The  semi-circular  canals  are  half-elliptical  or  C-shaped  canals 
which  proceed  from  the  vestibule  and  return  to  it  again.  They 
are  three  in  number.  The  horizontal  lies  with  its  convexity 
directed  laterally.  The  other  two  are  vertical  in  position,  form- 
ing a  right  angle  with  each  other.  The  two  openings  of  the 
anterior  vertical  semi-circular  canal  are  near  each  other  and  at 
about  the  same  height.  The  openings  of  the  posterior  vertical 
38 


594 


SEMI-CIRCULAR   CAXALS. 


canals  are  above  each  other.   The  horizontal  canal  is  surrounded, 
as  it  were,  by  the  two  vertical  ones. 

There  are  considerable  variations  in  different  individuals,  in 
the  length  and  curvature  of  the  semi-circular  canals,  yet  the 
general  shape  of  these  parts  remains  the  same. 


FIG.  119. — Section  of  Temporal  Bone  of  Right  Side  through  the  Cochlea  (anterior  view, 
actual  size).  1,  Mastoid  cells;  2,  internal  auditory  canal;  3.  modiolus  and  lamina  spiralis; 
4,  cochlea  ;  5,  superior  semi-circular  canal ;  6,  horizontal  semi-circular  canal. 

The  length  of  the  anterior  vertical  canal,  measured  on  the 
convex  border,  with  the  ampulla  and  the  common  crus,  is  about 
-f  of  an  inch ;  that  of  the  posterior  is  |£  of  an  inch,  of  the  horizon- 
tal £  of  an  inch.  The  part  common  (canalis  communis)  to  the 
two  vertical  canals  is  from  ^  to  |  of  an  inch  in  length.  The 
diameter  in  a  grown  man  varies  from  to  -  of  an  inch. 


FIG.  120. — Osseous  Cochlea  and  Semi- 
circular Canals,  with  Stapes  Bone.  Left 
Ear  of  Adult  (after  Rudinger). 


FiG.  121.— Right  Osseous  Vestibule, 
Semi-circular  Canals,  Cochlea,  and  Ossi- 
cula  Auditus  of  Newly  Born  (after  Ru- 
dinger). 


Wharton  Jones  makes  their  calibre  about  one-twentieth  of  an 
inch  in  a  direction  from  the  concavity  to  the  convexity  of  their 
curve. 

Since  the  semi-circular  canals  all  open  at  both  ends  into  the 
vestibule,  there  would  be  six  orifices  were  not  one  of  the  orifices 
common  to  two  of  the  canals.  There  are,  consequently,  five. 
These  openings  are  called  ampullae  (flasks)  from  their  shape,  and 
are  more  than  twice  the  diameter  of  the  tubes.  The  inner 


SEMI-CIRCULAE   CANALS. 


595 


extremity  of  the  superior  vertical  canal  has  a  common  open- 
ing into  the  vestibule  with  the  posterior  vertical. 


FIG.  122. — The  Right  Osseous  Labyrinth  of  a  Newly  Born  Subject  opened  on  its  Posterior 
Surface  (after  Riidinger).  1,  Cochlear  f  enestra ;  2,  the  osseous  spiral;  3,  the  osseous  spiral 
canal  of  the  cochlea — canalis  spiralis  cochleae — divided  by  the  spiral  into  two  parts,  scalaj,  or 
stairways,  the  lower  the  scala  tympani,  the  upper  the  scala  vestibuli ;  4,  the  basis  of  the  inter- 
nal auditory  canal,  with  the  entrance  to  the  Fallopian  canal  and  the  maculae  cribrosse.  The 
latter  receive  the  fibres  of  the  auditory  nerve,  and  the  vessels  entering  with  it  into  the  laby- 
rinth ;  5,  the  osseous  vestibule,  opened  on  its  posterior  wall ;  6,  the  posterior  semi-circular 
canal ;  7,  the  upper  semi-circular  canal ;  9,  horizontal  semi-circular  canal. 

According  to  Henle,1  in  the  later  years  of  life  the  semi-cir- 
cular canals  increase  in  length  ;  the  horizontal  canal  increases 


FIG.  123. — Section  of  Right  Temporal  Bone,  showing  Osseous  Semi-circular  Canals  (actual 
size).  1,  Internal  auditory  canal ;  2,  superior  semi-circular  canal ;  3,  external  semi-circular 
canal  ;  4,  posterior  semi-circular  canal. 

the  most,  and  the  anterior  vertical  the  least.  The  canals  also 
increase  very  slightly  in  width ;  about  0.7  mm.  according  to 
Pyrtl. 

THE  COCHLEA. 

This  part  of  the  internal  ear  is  so  named  from  its  resemblance 
to  a  common  snail ;  a  resemblance  which  is  very  marked.  It  is 
one  of  the  most  remarkable  instances  in  the  whole  body  of  the 
compact  packing  of  very  important  parts. 

1  Lehrbuck,  p.  762. 


596  COCHLEA. 

The  osseous  cochlea  lies  in  front  of  the  vestibule,  and  behind 
the  carotid  canal,  and  forms  the  promontory  by  pressing  out,  as 
it  were,  the  bone  toward  the  tympanic  cavity.  Inward  it  strikes- 
upon  the  blind  end  of  the  internal  auditory  canal.  The  cochlea 
is  aptly  compared  to  a  tube  tapering  toward  one  extremity 
where  it  ends  in  a  cul-de-sac,  and  which  is  coiled  like  the  shell 
of  a  snail  round  an  axis  or  central  pillar.  Then  we  must1  sup- 
pose this  tube  divided  into  passages  by  a  thin  partition  running 
throughout  its  length,  and  spirally  around  its  axis. 

The  tube  of  which  the  cochlea  is  formed — the  canalis  spiralis 
cochleae,  is  about  an  inch  and  a  half  long,  about  one-tenth  of  an 
inch  in  diameter  at  its  commencement,  and  about  one-twentieth 
at  its  termination.  It  makes  two  turns  and  a  half  turn,  in  a  di- 


c  m 


a  e 

FIG.  124. — Osseous  Cochlea  (Right)  of  the  Newly  Born,  opened  from  the  Outer  Surface 
(after  Henle).  *  v,  Scala  vestibuli ;  »  t,  scala  tympani ;  I  .s,  lamina  spiralis ;  c  s,  crista 
semilunaris;  a  c,  inner  opening  of  the  aqneductus  cochlea;  c  m,  canalis  centralis;  s  m, 
canalis  spiralis  modioli. 

rection  from  below  upward,  from  left  to  right  in  the  right  ear, 
and  from  right  to*  left  in  the  left  ear.  The  apex  of  the  coil  is 
directed  forward  and  outward.  The  base  of  the  spiral  tube  runs 
into  the  vestibule.  The  cul-de-sac  at  the  apex  forms  a  kind  of 
vaulted  roof  called  the  cupola. 

The  first  turn  of  the  cochlea  has  a  circular  sweep  of  a  quarter 
of  an  inch,  and  is  wider  than  the  rest.  It  is  separated  from  the 
second  turn  by  a  soft  bony  substance,  which  extends  a  little 
way  between  the  second  and  third.  The  axis  is  composed  of 
the  internal  walls  of  the  tube  of  the  cochlea  and  the  central 
space  circumscribed  by  their  turns,  in  which  space  are  the  fila- 
ments of  the  cochlear  nerve  running  In  small  bony  canals.  The 
axis  is  about  one-seventh  of  an  inch  in  thickness  at  the  first  turn, 


COCHLEA.  597 

but  it  becomes  thinner  from  the  second  turn,  on  to  its  termina- 
tion. The  axis  terminates  within  the  last  half  coil  or  cupola,  in 
'a  delicate  bony  lamella,  which  resembles  the  half  of  a  funnel, 
divided  longitudinally,  and  called  the  infundibulum  (funnel). 
Wharton  Jones  compares  the  appearance  of  the  axis  of  the 
cochlea  after  the  outer  walls  have  been  removed,  to  the  ordinary 
pictorial  representations  of  the  tower  of  Babel. 

The  cavity  of  the  cochlea  is  divided  into  two  parts  or  pas- 
sages, called  scalce,  by  a  thin  osseous  and  membranous  spiral 
lamina,  lamina  spiralis  ossea.  The  lower  one  communicates 
with  the  cavity  of  the  tympanum  through  the  fenestra  rotunda, 
the  upper  with  the  recessus  hemisphsericus  (see  Fig.  118,  of  the 
vestibule).  The  former  space  is  therefore  called  the  scala  tym- 


FlG.  125. — Section  through  Cochlea  and  Vestibule  (left  side,  actual  size.  From  Professor 
Darling's  museum).  1,  Carotid  canal ;  2,  broken  styloid  process  ;  3,  first  turn  of  cochlea  ;  4, 
vestibule ;  A,  A,  superior  semi-circular  canal ;  B,  B,  external  semi-circular  canal ;  C,  aquae- 
ductus  Fallopii ;  Z>,  auditory  nerve  channel. 

pani,  the  latter  scala  vestibuli.  In  the  scala  tympani,  just 
above  the  membrana  tympani  secondaria,  which  closes  the  fen- 
estra rotunda,  is  an  opening,  called  the  entrance  of  the  aque- 
duct to  the  cochlea.  The  two  scalse  communicate  at  the  apex 
of  the  cochlea  by  a  common  opening  called  the  helicotrema  (« 
twisted  foramen).  This  communication  exists  in  consequence 
of  the  want  of  a  lamina  spiralis  in  the  last  half  coil  of  the 
canal. 

Two  very  small  canals  called  aqueducts  open  by  one  ex- 
tremity into  the  labyrinth,  and  by  the  other  on  the  surface  of 
the  petrous  portion  of  the  temporal  bone. 


598 


MEMBRANOUS   LABYRINTH. 


PERIOSTEUM  OF  THE  LABYRINTH. 


The  periosteum  that  covers  the  walls  of  the  osseous  canal 
is,  with  the  exception  of  that  on  the  outer  wall  of  the  cochlea, 
very  delicate.  Henle '  compares  the  periosteum  of  the  labyrinth 
to  one  of  the  parts  of  the  choroid,  because  it  is  strewn  with  nu- 
cleated pigment  cells.  There  are  also  calcareous  deposits.  It 


FIG.  126.  —  Periosteum  of  the  Labyrinth 
(after  Henle). 


FIG.  127.— Periosteum  of  the  Outer  Wall  of 
the  Cochlea  (after  Henle). 


is  very  difficult,  according  to  Henle,  to  separate  the  periosteum 
of  the  labyrinth,  without  also  detaching  bits  of  bone.  The 
periosteum  is  abundantly  supplied  with  blood-vessels. 


THE  MEMBRANOUS  LABYRINTH. 

Utricle  and  Membranous  Semi-circular  Canals. 

The  utricle  is  an  elliptical  tube,  situated  on  the  median  wall 
of  the  vestibule.  Its  longest  diameter  corresponds  to  the  height 
of  the  vestibule.  By  means  of  a  fine  vascular  and  nervous  net- 
work, and  a  very  delicate  connective  tissue,  it  is  fastened  to  the 
recessus  ellipticus  of  the  vestibule. 

The  membranous  semi-circular  canals  are  but  the  lining  of 
the  osseous  canals,  and,  of  course,  of  the  same  shape.  The 
membranous  canals  open  into  the  utriculus  with  five  openings, 
just  as  do  the  osseous  tubes  in  the  vestibule.  At  the  ampullae, 
the  membranous  canal  fills  up  the  osseous  very  completely  ;  but 
there  is  some  space  between  the  other  parts.  The  walls  of  these 


1  Lehrbuch,  p.  774. 


MEMBKANOUS   LABYKINTH. 


599 


structures  are  transparent,  as  clear  as  water,  and  of  great  deli- 
cacy. After  the  endolymph  is  removed,  they  fall  together  and 
arrange  themselves  in  rigid  folds.  There  is, 
however,  a  point  that  is  firmer,  called  the 
macula  acustica,  situated  on  the  median 
wall  of  the  utricle,  where  a  twig  of  the 
auditory  nerve  reaches  this  wall.  The  por- 
tion of  the  ampulla  that  contains  the  termi- 
nation of  the  nerve,  and  which  is  detected 
by  the  naked  eye  as  a  whitish-yellow  spot, 
is  also  of  firmer  consistency.  This  point  is 
called  the  crista  acustica  by  Max  Schultze. 
It  comprises  about  one-third  of  the  wall  of 
the  ampulla.  It  is  sometimes  surrounded  by  a  pigmented  line 
and  also  receives  nerve-twigs. 

The  wall  of  the  membranous  semi-circular  canals  is  from 
0.02  mm.  to  0.03  mm.  in  thickness,  and  is  composed  of  various 
layers. 

The  membrana  propria  is  of  reticulate  and  nuclear  fibrous 
tissue,  of  which  the  periosteum  also  consists.  It  is  perforated 


FIG.  128.— Utricle  and 
Membranous  Semi-circular 
Canals  of  the  Left  Side. 


FIG.  129.— A  Piece  of  the  Wall  of  .the  Utricle,  with  the  Otoliths  (after  Henle). 

by  blood-vessels.  There  is  a  basal  membrane  next  the  mem- 
brana propria,  and  on  the  inner  surface  pavement  epithelium. 

The  macula  and  crista  acustica  that  have  been  mentioned, 
are  thickenings  of  the  membrana  propria,  caused  by  the  min- 
gling of  connective  tissue,  and  the  ending  of  the  nerves. 

The  otolith  of  the  utriculus  of  the  mammalia  is  a  smooth, 
irregularly  demarcated  and  uneven  mass  of  chalky  white  pow- 
der. It  was  called  otoconia  by  Breschet,  ear-sand  by  Lincke, 


600  DUCTUS    COCHLEAEIS. 

and  ear-crystal  by  Huschke.  The  powder  is  held  together  by 
an  almost  mucous  substance,  and  consists  of  crystals  of  carbo- 
nate of  lime,  of  varying  shape  and  size.  The  largest  are  only 
0.012  mm.  long  and  0.008  mm.  broad.  They  are  too  small  to 
allow  the  crystal  form  to  be  recognized.  Henle  says  it  is  un- 
known how  the  otolith  is  fastened  on  to  the  wall  of  the  utricle. 


SACCULE. 

The  saccule-is  of  the  shape  of  a  broad  flask  with  narrow 
neck.  Its  body  (about  T^  inch  in  diameter)  lies  in  the  recessus 
sphsericus  of  the  vestibule.  The  neck  (canalis  reunicus,  about 
3^  inch  long  and  y^  inch  in  diameter)  of  this  bottle  or  flask  pro- 
ceeds from  the  lower  wall,  downward  and  backward,  and  sinks 
into  the  upper  wall  of  the  vestibular  end  of  the  ductus  cochle- 
aris,  at  nearly  a  right  angle,  so  that  a  blind  sac  is  formed  at  the 
junction  of  the  two  parts.  Henle  compares  it  to  the  passage  of 
the  oesophagus  into  the  stomach,  and  of  the  small  intestine  into 
the  ccecum. 

THE    DUCTUS   COCHLEARIS   (LAMINA    SPIRALIS    MEMBRANACEA   OF   THE 

OLD   ANATOMISTS). 

The  ductus  cochlearis  begins  with  the  blind  sac  in  the  vesti- 
bule that  has  been  described,  and  passes  through  the  whole 
cochlea  to  the  apex,  in  which  it  ends  again  as  a  blind  sac.  The 
lower  end  rests  in  the  recessus  cochlearis,  and  the  upper  in  the 
cul-de-sac  of  the  cupola.  The  ductus  cochlearis  is  attached  on 
one  side  to  the  lamina  spiralis  ossea,  and  on  the  other  to  the 
outer  wall  of  the  osseous  cochlear  canal.  On  a  transverse  sec- 
tion the  ductus  cochlearis  is  seen  to  be  triangular  in  shape,  and 
has,  of  course,  three  walls  or  sides.  Two  of  these  walls  diverge 
from  the  edges  of  the  lamina  spiralis,  and  the  other  corresponds 
to  the  portion  of  the  cochlear  wall,  between  which  the  insertion 
of  the  two  others  is  made.  The  lower  wall  of  the  ductus  coch- 
learis, which  is  turned  toward  the  scala  tympani,  is  called  the 
tympanal ;  the  upper,  which  separates  the  ductus  cochlearis 
from  the  scala  vestibuli,  is  called  the  vestibular  wall. 

On  the  osseous  border  of  the  lamina  spiralis  is  a  soft  struc- 
ture, only  to  be  seen  in  the  uninjured  specimen  of  the  cochlea, 
which  lengthens  the  lamina  spiralis  toward  the  calibre  of  the 
ductus  cochlearis.  It  is  called  by  Henle  the  limbus  laminse  spi- 
ralis. It  is  developed  from  the  periosteum  of  the  lamina  spi- 
ralis. This  structure  gradually  decreases  in  breadth  and  height 
from  the  base  to  the  apex  of  the  cochlea.  The  edge  of  the  osse- 


DUCTUS   COCHLEAEIS.  601 

ous  lamina  recedes  more  and  more  at  the  same  time  from  the 
free  border  of  the  limbus.  This  free  border  becomes  a  furrow, 
called  by  Huschke  the  sulcus  spiralis,  having,  of  course,  two 
lips.  The  upper  lip  is  the  labium  vestibulare ;  the  lower,  the 
labium  tympanic um.  The  vestibular  wall  of  the  ductus  cochle- 
aris  passes  off  from  the  upper  surface  of  the  lamina  spiralis  in  a 
line  nearly  corresponding  to  the  inner  attachment  of  the  limbus 
laminae  spiralis,  so'  that  the  latter  is  almost  completely  drawn 
into  the  ductus  cochlearis. 

The  upper  surface  of  the  vestibular  lip  of  the  limbus  lamina 
spiralis  is  covered  by  striae,  which  on  front  view  resemble  the 
anterior  surface  of  the  incisor  teeth,  and  hence  Huschke  calls 
them  the  auditory  teeth.  These  furrows,  or  striae,  are  filled  by 


FIG.  130. — Transverse  Section  of  a  Cochlear  Spiral,  from  a  Cochlea  softened  in  Hydro- 
chloric Acid  (after  Henle).  The  dotted  lines  indica.te  sections  of  the  membrana  tectoria  and 
the  auditory  rods  ;  I  s.  lamina  spiralis  ;  II  s,  limbus  laminae  spiralis  ;  s  v,  scala  vestibule  ;  s  t, 
scala  tympani ;  d  c,  ductus  cochlearis  ;  I  s  p,  ligamentum  spirale  ;  v,  membrana  vestibularis ; 
*,  membrana  basilaris  ;  c,  outer  wall  of  ductus  cochlearis  ;  *,  bulging  of  this  wall. 

small  rounded  cells.  Their  number  may  run  as  high  as  2500. 
The  limbus  is  composed  of  connective  tissue,  running  in  a  radi- 
ate direction  in  the  furrows,  or  striae  ;  beneath  these  furrows  the 
connective  tissue  is  reticulate. 

Henle  compares  the  labium  vestibulare  to  a  roof  over  the 
sulcus  spiralis,  and  the  labium  tympanicum  to  a  floor.  Within 
the  labium  tympanicum  run  very  fine  nerve-fibres  from  the  tis- 
sue of  the  auditory  nerve  to  the  ductus  cochlearis.  The  labium 
tympanicum  consists  of  two  layers,  which  include  the  nerve- 
fibres  between  them,  and  then  unite  beyond  it  in  a  sharp  border, 
from  which  the  membrana  basilaris  proceeds.  This  membrana 
basilaris,  according  to  Henle.  appears  as  a  process  of  the  upper 
layer  of  the  labium  tympanicum.  There  is,  however,  a  struc- 
ture between  them,  which  corresponds  to  the  periphery  of  the 
nerve  bundles. 


602  CORTl'S   ORGAN — DUCTUS   COCIILEARIS. 

On  the  outer  portion  of  the  upper  surface  of  the  labium  tym. 
panicum  are  four  radiate  striae,  which  Henle  considers  as  marks, 
of  the  nerve  bundles  running  on  the  lower  surface  of  this  layer. 
At  'the  periphery  of  these  there  are  other  openings. 

The  membrana  vestibularis  is  attached  to  the  beginning  of 
the  upper  border  of  the  ridge  of  the  spiral  and  to  the  outer 
cochlear  wall.  There  are  three  layers  in  this  membrane,  which 
by  Kolliker  is  called  Reissners  membrane.  It  is  epithelial  tissue, 
which  in  embryonal  life  seizes  upon  the  vestibular  side  of  the 
cochlear  canal.  This  membrane  has  a  number  of  blood-vessels. 

The  membrana  basilaris  is  well  shown  in  the  preceding  figure, 
and  being  the  part  upon  which  rests  the  organ  of  Corti,  has  at- 
tracted very  much 'attention  from  anatomists.  It  is  a  continua- 
tion of  the  labium  tympanicum.  It  gradually  increases  in  breadth 
from  the  base  to  the  apex,  in  the  same  proportion  that  the  lamina 
spiralis  with  its  limbus  decreases  in  size.  Its  breadth  in  the 
newly  born,  in  the  middle  of  the  first  turn  or  coil  of  the  cochlea, 
is  0.17  mm.;  at  the  end  of  the  second,  0.45.  This  space  is  divided 
into  two  parts  or  zones.  The  inner  was  called  by  Kolliker,  the 
habenula  tectu,  and  the  outer  by  Todd  and  Bowman,  the  zona 
pectinata.  Henle  gives  the  two  parts  the  simple  names  of  inner 
and  outer  zone.  On  the  inner  zone  are  found  the  structures 
making  up  what  is  known  as  Corti's  organ,  from  their  discov- 
erer, Marchese  Corti.1  The  outer  zone  is  rather  broader  than  the 
inner. 

The  basis  of  the  membrana  basilaris  is  a  structureless  mem- 
brane. On  the  outer  zone  especially  are  peculiar  knobby  points. 
Upon  this  structureless  membrane  are  the  parts  known  in  their 
totality  as  Corti's  organ.  The  fibres  of  this  structure  are  ar- 
ranged along  the  whole  length  of  the  membrana  basilaris. 
There  are  spaces  between  them,  so  that  they  have  a  certain 
resemblance  to  the  keys  of  a  piano. 

The  ligamentum  spirale  is  the  means  of  attaching  the  mem- 
brana basilaris  to  the  outer  wall  of  the  cochlear  canal.  The 
fibres  of  which  it  is  composed  are  like  those  of  periosteum. 

The  cavity  of  the  ductus  cochlearis  is  divided  into  parts  by  a 
membrane  running  parallel  to  the  membrana  basilaris.  The 
upper  part  is  filled  with  endolymph,  the  lower  contains  what 
Henle  calls  the  terminal  auditory  apparatus.  The  membrane 
which  divides  the  ductus  cochlearis  into  two  parts  is  called  the 
membrana  tectoria  by  Claudius,  but  Corti's  membrane  by  Kol- 
liker. The  membrana  tectoria  is  divided  into  three  zones.  The 

1  Corti  was  formerly  prosector  to  Professor  Joseph  Hyrtl,  and  made  the  first  exact 
microscopic  examination  of  the  lamina  spiralis  ossea,  and  membranacea. 


CORTl'S   RODS. 

middle  zone  is  the  denser ;  the  inner  is  structureless  and  has 
numerous  openings.  The  outer  zone  is  made  up  of  a  very  fine 
and  friable  network.  It  is  probable,  according  to  Henle,  that 
the  membrana  tectoria  is  firmly  fastened,  and  that  it  is  riot 
possible  for  it  to  press  closely  upon  the  parts  covered  by  it. 

TERMINAL  AUDITORY  APPARATUS. 

The  most  .important,  physiologically  speaking,  of  this  termi- 
nal apparatus  are  the  auditory  rods,  called  also  Corti's  teeth,  or 
Corti's  fibres.  They  are  arranged  in  regular  order,  very  like  the 
cords,  hammers,  or  keys  of  a  piano.  They  are  shaped  like  a 
Roman  S,  having  slender  cylindrical  bodies  and  broad  ends  con- 
taining granular  protoplasm.  There  are  two  rows  of  these  fibres, 
an  inner  and  an  outer.  The  inner  rods  arise  from  the  membrana 


PIG.  131.— From  the  Terminal  Auditory  Apparatus  of  a  Cat  (after  Henle).     i,  Outer  ends  of 
the  inner  fibres ;  e,  outer  fibres ;  3,  outer  covering  cells ;  4,  epithelial  cells.     (500  x  1.) 

basilaris,  on  which  their  internal  extremities  are  fastened,  more 
or  less  abruptly,  toward  the  membrana  tectoria,  without,  how- 
ever, being  united  to  the  latter.  The  outer  rods  or  fibres  join, 
with  their  inner  extremities,  the  outer  end  of  the  inner  fibres. 
Their  external  terminations  rest  011  the  membrana  basilaris. 
There  are  two  varieties  of  the  inner  row  of  fibres  or  rods  ;  one  is 
smooth  and  elliptical  in  shape,  the  other  cylindrical  and  broader 
at  each  end. 

The  outer  row  of  rods  is  cylindrical  in  shape,  and  th'ey  stand 
at  a  greater  distance  apart  than  the  inner.  The  estimated  num- 
ber of  inner  pillars  is  6000,  of  the  outer  4500.  The  inner  row  of 
fibres  is  always  shorter  than  the  outer.  They  join  together  and 
form  a  roof  over  the  inner  zone  of  the  membrana  basilaris.  The 
base  of  this  roof  is  0.1  mm.  in  breadth.  The  structure  of  these 
rods,  as  shown  by  the  action  of  reagents,  is  a  tissue  as  hard  as 
cartilage. 


AUDITORY   NERVE. 

Henle  calls  the  terminations  of  the  two  rows  of  rods  upon  the 
membrana  basilaris,  the  lower  extremities  ;  and  the  extremities 
which  join  to  make  the  roof,  the  upper  extremities.  The  cells 
found  in  the  ductus  cochlearis,  auditory  cells,  are  nucleated, 
round,  and  cylindrical.  A  layer  of  them  covers  the  sulcus  spi- 
ralis,  Reissner's  membrane,  and  the  outer  wall  of  the  ductus 
cochlearis.  Upon  the  inner  pillars  lies  -a  single  row  of  conical 
cells  with  large  nuclei.  They  send  processes  into  the  rows  of 
small  cells  lying  next  toward  the  sulcus  spiralis,  the  granular 
laj^er.  The  ends  turned  toward  the  heads  of  the  rods  bear  tufts 


2  4      ** 

FIG.  132.  FIG.  133. 

FIG.  132.— Profile  View  of  Outer  and  Inner  Rods. 

Fig.  133. — Membrana  Basilaris  (b),  with  the  terminal  nerve-fibres  (n)  and  the  inner  and 
outer  rods ;  and  1 ,  inner  ;  2,  outer  floor  cells  ;  4,  attachment  of  the  roof  cells  ;  **,  epithelium. 

of  stiff  immovable  cilia.  These  cells  are  called  inner  hair-cells. 
Their  number  is  computed  at  3300.  On  the  outer  rods  lie  three 
or  four  rows  of  double  nucleated  cells,  connected  by  slender  pro- 
cesses to  the  membrana  basilaris  and  membrana  reticularis,  and 
bearing  also  tufts  of  cilia.  Their  number  is  computed  at  18,000. 
The  cilia  of  the  cells  are  received  in  the  lamina  reticularis  in 
corresponding  rows  of  openings.  Waldeyer  regards  the  cells,  as 
also  the  rods  of  Corti,  as  epithelial  structures.  Henle  describes 
another  layer  of  cells  lying  on  the  membrana  basilaris  as  floor 
cells. 

The  membrana  reticularis  is  the  second  of  the  component 
parts  of  the  terminal  auditory  apparatus.  It  arises  from  the 
articulation  of  the  rods  or  fibres,  and  extends  to  the  outer  wall 
of  the  cochlea  parallel  to  the  lamina  basilaris.  It  is  supposed  to 
be  a  ligament  to  bind  the  rods  together.  The  tissue  of  the  lam- 
ina reticularis  is  not  less  firm  than  that  of  th«  rods,  but  it  is 
delicate. 

AUDITORY  NERVE. 

The  Auditory  Nerve  (Nervus  acusticus).  —  The  auditory 
nerve,  or  portio  mollis  (soft  part  of  the  seventh  nerve),  is  the 
nerve  of  the  sense  of  hearing,  and  is^istributed  exclusively  to 
the  internal  ear.  The  auditory  nerve  arises  by  two  roots  in  the 


AUDITORY    NERVE. 


605 


medulla  oblongata.  One  ganglionic  nucleus  of  origin  is  in  the 
floor  of  the  fourth  ventricle.  The  other  is  in  the  cms  cerebelli 
ad-medullam.  The  roots  of  the  nerve  are  connected,  on  the 
under  surface  of  the  middle  peduncle,  with  the  gray  substance 
of  the  cerebellum,  with  the  flocculus,  and  with  the  gray  matter 
at  the  border  of  the  calamus  scriptorus.  The  nerve  winds 
around  the  restiform  body,  from  which  it  receives  fibres,  and 
passes  forward  across  the  posterior  border  of  the  crus  cerebelli, 
in  company  with  the  portio  dura,  or  facial  nerve,  from  which  it 
is  partly  separated  by  a  small  artery.  It  then  passes  into  the 
meatus  auditorius  internus,  where  some  minute  filaments  con- 
nect them  together. 

4  3 

r 

It      2 


FIG.  134. — Expansion  of  the  Right  Cochlear  Xerve,  seen  from  the  Base  of  the  Cochlea, 
from  a  Labyrinth  softened  in  Hydrochloric  Acid  (after  Henle).  1,  The  branches  entering 
through  foramina  ;  2,  twig  passing  into  the  modiolus  ;  3,  network  in  the  osseous  lamina  spi- 
ralis  ;  4,  network  on  its  border ;  1 1,  labium  tympanicum  ;  z  i,  zona  interna  ;  2  e,  zona  externa 
of  the  membrana  basilaris  ;  I  «,  ligamentum  spirale.  (15  x  1.) 

The  auditory  nerve  is  remarkable  for  the  delicacy  of  its 
structure,  which  caused  the  older  anatomists  to  give  it  the 
name  of  portio  mollis^  It  has  only  a  very  thin  iieurilemma. 

At  the  bottom  of  the  meatus  the  facial  nerve  enters  the  Fallo- 
pian canal,  the  auditory  divides  into  two  branches,  vestibular 
and  cochlear. 

The  cochlear  nerve  gives  off  a  small  branch,  which  passes  to 
the  vestibular  extremity  of  the  ductus  cochlearis,  and  through 
the  fourth  macula  cribrosa,  to  the  partition  wall  of  the  two  sac- 
cules  in  the  vestibule.  From  the  trunk  of  the  nerve  a  number 
of  fine  twigs  arise,  which  pass  through  foramina  direct  to  the 
lamina  spiralis  of  the  lower  coil  of  the  cochlea.  The  remainder 
of  the  cochlear  nerve  enters  the  modiolus,  and  is  divided  into 
anastomotic  divisions.  The  fibres  become  separated  from  the 


606  AUDITORY   NERVE. 

trunk  in  a  line  corresponding  to  the  course  of  the  canalis  spi- 
ralis  modioli,  and  permeate  this  canal.  Here,  by  the  addition 
of  ganglion  cells,  they  become  gangliose  strise,  and  finally  end, 
at  almost  a  right  angle  to  the  trunk,  in  the  osseous  lamina  spi- 
ralis. 

The  vestibular  nerve,  after  a  slight  gangliose  expansion, 
divides  into  three  branches  : 

1.  Superior. — This  passes  through  the  macula  cribrosa  supe- 
rior, and  ends  by  three  branches  to  the  utricle  and  ampulla  of 
the  superior  vertical  and  horizontal  semi-circular  canals. 

2.  The  middle  passes  through  the  macula  cribrosa  media  to 
the  saccule. 

3.  The  inferior  passes  through  a  bony  canal  of  its  own  to 
the  ampulla  of  the  inferior  vertical  semi-circular  canal.     The 
terminal  nerve-fibres  pass  from  the  lamina  spiralis  through  fine 
holes  in  the  labium  tympanicum,  and  in  the  membrana  vesti- 
bularis  into  the  ductus  cochlearis. 

They  run  in  a  radiate  direction,  pass  through  the  granular 
layer,  where  some  end  in  inner  hair-cells  and  others  run  be- 
tween the  rods  of  Corti  and  across  the  tunnel  formed  by  them, 
to  end  in  outer  hair-cells.  There  are  probably  other  nerve-fibres 
running  in  a  spiral  course  among  the  granular  layer  and  the 
outer  hair-cells. 

Todd  arid  Bowman  regard  the  vestibular  nerve  as  direct  pro- 
longation of  the  white  matter  of  the  brain. 

In  the  internal  auditory  canal,  the  portio  mollis  forms  a  con- 
nection with  the  portio  dura  by  means  of  a  few  fascicles  of 
fibres,  which  constitute  what  Wrisberg  called  the  "portio  inter- 
media." It  is  not  decided  whether  the  connecting  link  proceeds 
from  the  auditory  to  the  facial  nerve,  or  from  the  latter  to  the 
former.  Todd  and  Bowman  believe  it  probable  that  the  facial 
nerve  sends  some  filaments  to  the  blood-vessels  of  the  labyrinth 
and  the  muscular  structure  of  the  internal  ear. 

The   internal  auditory  canal  (meatus  auditorius  internus) 

begins  at  about  the  centre  of  the  petrous  portion  of  the  temporal 

•  bone  by  a  large  orifice  with  smooth  rounded  edges,  and  runs 

directly  outward  about  one-eighth  of  an  inch  to  end  in  a  blind 

fossa. 

There  are  four  depressions  in  the  fossa.  These  are  perfo- 
rated by  fine  foramina,  through  which  the  fibres  of  the  acoustic 
nerve  enter  the  labyrinth.  Three  of  them  correspond  to  the 
maculae  cribrosa.  The  fourth  lies  opposite  the  base  of  the  coch- 
lea. It  is  spiral-shaped,  has  spiral-shaped  openings,  and  is  called 
the  tractus  spiralis  foraminosus. 


BLOOD-VESSELS — PHYSIOLOGY.  607 

BLOOD-VESSELS. 

The  blood  passes  to -the  internal  ear  through  the  auditiva 
interna  artery,  which  is  a  branch  of  the  basilar,  according  to 
Hyrtl.  The  basilar  comes  from  the  vertebral  and  the  vertebral 
from  the  subclavian.  After  the  internal  auditory  artery  has 
entered  into  the  meatus  auditorus  internus,  it  divides  into  a 
vestibular  and  cochlear  branch.  The  cochlear  branch  divides 
in  numerous  branches  which  pass  through  the  foramina  of  the 
tractus  spiralis  foraminosus  into  the  modiolus,  and  then  go  on 
between  the  layers  of  the  lamina  spiralis,  and  are  finally  lost  in 
the  spirals  of  the  cochlea.  The  vestibular  artery  passes  through 
the  posterior  wall  of  the  vestibule  in  numerous  fine  twigs  to  the 
soft  structures  of  the  vestibule  and  semi-circular  canals.  The 
stylo-mastoid  artery  is  said  to  give  several  small  branches  to 
the  labyrinth.  It  is  important  to  observe  the  fact  to  which  Von 
Troltsch  calls  attention — that  the  blood-supply  of  the  labyrinth 
and  of  the  middle  ear  are  nearly  separate  and  independent  of 
each  other.  This  may  explain  the  relative  infrequency  of  the 
extension  of  disease  of  the  middle  ear  to  the  internal  ear. 


THE  PHYSIOLOGY  OF  THE  INTERNAL  EAR.1 

The  vibrations  of  the  atmosphere  are  conveyed  through  the 
ossicles  and  fenestra  ovalis  to  the  perilymph  of  the  labyrinth. 
They  pass  as  waves  over  the  vestibule,  semi-circular  canals,  and 
other  parts  of  the  labyrinth,  and  are  there  transmitted  to  the 
endolymph.  A  vibration  passes  from  the  vestibule  into  the  scala 
vestibuli  of  the  cochlea,  and  passing  down  the  scala  tympani 
ends  as  an  impulse  against  the  fenestra  rotunda.  The  variations 
in  pressure  of  the  fluid  of  the  labyrinth,  which  is  surrounded  by 
particularly  firm  bony  walls,  thus  excited  by  the  motions  of  the 
foot-plate  of  the  stapes  bone,  are  compensated  for  by  a  move- 
ment of  the  membrane  of  the  fenestra  rotunda.  The  helico- 
trema,  the  small  opening  through  which  the  two  scalse  of  the 
cochlea  communicate,  allows  the  membrana  basilaris  with  the 
parts  lying  upon  it  (Corti's  organ)  to  be  set  in  motion.  Buck's  in- 
vestigations lead  him  to  believe  that  "no  communication  exists 
between  the  two  scalse  in  the  immediate  vicinity  of  the  cupola," 
unless  the  opening  spoken  of  so  vaguely  by  the  authors,  be  micro- 
scopic in  size."  This  negative  assertion  has  not  been  confirmed 

•Foster:   Text-Book  of  Physiology.     Hartmann  :   Lehrbuch.     Hensen  :   Handbuch 
xler  Physiologie  von  Hermann,  Leipzig,  1880.     Politzer  :   Lekrbuch. 
2  Treatise  on  the  Ear,  p.  12. 


608 


PHYSIOLOGY   OF   INTERNAL   EAR. 


by  other  anatomists,  and  the  opening  is  still  described  by  those 
who  have  written  since  Buck's  statement  was  made. 

The  exact  function  of  the  individual  portions  of  the  labyrinth, 
in  spite  of  the  investigations  of  the  physiologists,  is  not  yet  posi- 
tively settled.  According  to  Helmholtz,  the  vestibule  and  am- 
pullae are  adapted  to  the  perception  of  noises,  irregular  vibra- 


Labyrinth  or  internal 
ear. 


FIG.  135. — A  diagram  designed  to  illustrate  the  Physiology  of  the  Labyrinth  (Professor  A. 
L.  Ranney).  1,  External  auditory  canal ;  2,  the  membrana  tympani ;  3,  the  tympanic  cavity 
with  its  chain  of  bones  connecting  2  with  4;  4,  the  fenestra  ovalis ;  5,  the  utricle,  communi- 
cating with  the  semi-circular  canals  (11,  12,  and  13) ;  6,  the  saccule,  communicating  with  the 
scala  vestibuli  of  the  cochlea  (s  v) ;  7,  the  ampullae ;  8,  the  fenestra  rotunda,  opening  from 
the  scala  tympani  (s  <)  into  the  cavity  of  the  tympanum  (3) ;  9,  the  Eustachian  tube,  allowing  of 
the  entrance  of  air  from  the  pharynx  into  the  tympanic  cavity  ;  10,  the  internal  auditory 
canal,  transmitting  the  acoustic  nerve  ;  11,  12,  and  13,  the  semi-circular  canals;  14,  the  open- 
ing of  the  mastoid  cells  into  the  tympanic  cavity  (3)  and  the  external  auditory  canal  (1) ;  s  v, 
the  scala  vestibuli  of  the  cochlea ;  s  <,  the  scala  tympani  of  the  cochlea ;  c,  the  cupola. 

tions,  while  the  cochlea  perceives  periodic  vibrations — tones. 
Helmholtz  also  showed  that  it  is  probable,  that  the  part  of  the 
cochlea  near  the  fenestra  rotunda  vibrates  more  easily  to  high 
notes,  or  those  with  many  vibrations  in  a  second,  while  that  in 
the  cupola  vibrates  more  readily  to  low  tones.  The  membrana 
basilaris  of  the  cochlea  increases  in  width  from  the  lowest  wind- 
ing of  the  cochlea  to  the  cupola.  Helmholtz  says  that  the  mem- 
brana basilaris  has  a  system  of  cords  corresponding  to  its  stripes, 
of  which,  for  certain  tones,  only  a  limited  number  vibrate.  The 
perception  of  the  high  tones  is  caused  by  the  lower  section  of  the 
membrana  basilaris,  and  of  the  low  or  deep  ones  by  the  superior 


PHYSIOLOGY   OF   INTERNAL   EAR.  609 

parts.  This  corresponds  with  the  clinical  experience,  that  pa- 
tients deaf  from  exudations  in  the  middle  ear,  encroaching  upon 
the  labyrinth,  hear  low  tones,  when  they  cannot  at  all  perceive 
high  ones.  The  case  of  atrophy  of  the  acoustic  nerve  in  the 
first  whorl  of  the  cochlea,  reported  by  Moos  and  Steinbrugge,1  is 
also  strong  evidence  in  support  of  this  view.  The  patient  was 
sixty-three  years  old.  His  ears  were  examined  fourteen  days  be- 
fore his  death.  He  suffered  from  loss  of  hearing  and  constant 
tinnitus.  The  loss  of  hearing  is  said  to  have  occurred  suddenly. 
He  could  not  hear  the  voice  at  all  on  the  right  side,  and  3  metres 
on  the  left.  He  died  of  carcinoma  of  the  right  anterior  central 
convolution,  he  also  had  carcinoma  of  the  stomach.  In  the  ear 
was  found,  as  has  been  said,  atrophy  of  the  nerve-fibres  of  the 
first  cochlear  whorl.  The  external  ear,  and  middle  ear,  except 
the  junction  of  the  stapes  with  the  vestibule,  were  in  a  normal 
condition.  There  was  rigidity  of  the  articulation.  There  was 
also  sclerosis  of  the  cells  of  the  mastoid  process.  The  patient 
during  life  was  found  very  deficient  in  the  power  of  hearing  high 
notes.  It  has  been  shown  by  Moos  and  others,  that  the  power 
of  hearing  conversation  well,  involves  capability  of  hearing 
high  notes. 

Although  Helmholtz's  theory  of  the  function  of  the  cochlea 
is  not  everywhere  positively  accepted,  the  weight  of  evidence 
seems  to  be  in  favor  of  the  view,  that  it  has  a  higher  function 
than  the  vestibule,  and  that  by  it  an  analysis  of  tune  is  made. 
The  place  that  Corti's  rods  long  held  as  the  terminal  organs  of 
hearing  must,  however,  be  abandoned,  for  Hasse  found  in  birds 
that  possessed  the  power  of  hearing  musical  tones  and  speech, 
that  while  Corti's  cells  were  developed  the  rods  of  Corti  were 
wanting. 

The  view  that  the  cochlea  alone  is  for  the  perception  of  tone, 
is  put  somewhat  in  doubt  by  Ranke's  and  Henseii's  experi- 
ments. On  microscopical  examination  of  living  heteropodes, 
Ranke  found  the  auditory  cilia  vibrating  rapidly  and  moving 
toward  the  otoliths,  in  the  aural  vesicle.  Hensen,  in  experiment- 
ing upon  crabs,  showed  that  when  tones  were  produced  a  certain 
number  of  cilia  vibrated  to  certain  tones. 

The  semi-circular  canals  seem  to  have  nothing  to  do  with  the 
hearing  function,  but  since  the  experiments  of  Flourens  it  is  gen- 
erally, although  not  universally,  accepted  that  they  are  the  parts 
chiefly  concerned  in  maintaining  the  equilibrium  of  the  body. 

The  greater  number  of  authorities  regard  them  as  the  organ 
of  the  sense  of  equilibrium,  but  this  view  is  not  everywhere 


1  Zeitschrift  fur  Ohrenheilkunde,  Bd.  X.,  p.  1.     Archives  of  Otology,  vol.  x.,  p.  1. 
39 


610  AUDITORY   NERVE. 

accepted.  Bottcher,  on  the  basis  of  experiments  like  those  of 
Flourens,  believes  that  the  symptoms  seen  after  injury  of  the 
semi-circular  canals  are  due  to  a  simultaneous  injury  of  the  cere- 
bellum. Moos  agrees  with  this  author  from  clinical  observa- 
tions made  upon  patients.  In  accordance  with  the  views  of 
Lussana  and  Berthold,  he  thinks  that  the  disturbances  of  co- 
ordination after  injury  of  the  semi-circular  canals  are  excited  by 
a  reflex  transmission  of  the  irritation  from  the  ampullar  nerves 
to  the  cerebellum. 

Hogyes,  quoted  by  Politzer,1  says  that  the  terminations  of 
the  auditory  nerve  in  the  vestibule  are  a  peculiar  apparatus  to 
regulate  the  movements  of  the  eyes  and  probably  also  those  of 
the  muscles  for  the  preservation  of  the  equilibrium  of  the  body. 
Lussana  separated  the  semi-circular  canals,  without  at  the  same 
time  irritating  the  nerves  of  the  ampullae  or  vestibule,  and  even 
after  the  labyrinth  was  entirely  destroyed,  no  disturbances  of 
co-ordination  were  seen.  Politzer's  experiments  with  the  supe- 
rior semi-circular  canal,  showed  that  the  fluid  of  the  labyrinth 
could  be  influenced  by  pressure  or  exhaustion  of  the  air  in  the 
auditory  canal  or  tympanum.  A  manometric  tube  was  placed 
in  the  superior  semi-circular  canal  after  having  been  filled  with 
fluid.  On  pressure  from  the  canal  or  tympanum  the  fluid  arose, 
and  on  exhaustion  it  sank.  These  experiments  were  verified  and 
amplified  by  Helmholtz  and  others. 


Sensory  Centre  of  Auditory  Nerve. 

Ferrier a  finds  the  sensory  centre  of  the  auditory  nerve  in  the 
temporal  lobe  of  the  cerebrum.  Its  anatomical  connection  with 
the  nuclei  and  roots  of  the  nerve  has  not  been  proven.  Ferrier 
observed  on  electric  irritation  of  the  superior  temporal  convo- 
lution on  the  exposed  brain  of  cats,  dogs,  and  monkeys,  a  sud- 
den elevation  of  the  auricle  of  the  opposite  side,  and  on  destruc- 
tion of  the  temporal  lobe  deafness  of  the  opposite  ear.  Munk,3 
quoted  by  Politzer,  got  the  same  results,  by  experiments  on 
dogs.  He  thinks  they  indicate  a  decussion  of  the  fibres  of  the 
auditory  nerve  in  the  brain. 

Munk  believes,  as  quoted  by  Politzer,  that  if  the  parts  of  the 
temporal  lobe,  termed  "hearing  spheres,"  were  removed,  and 
the  ear  of  the  same  side  destroyed,  the  animal  would  be  deaf. 
Munk  also  believes  that  the  posterior  part  of  the  hearing  sphere 

1  Text-book,  translation,  p.  682. 

s  The  Functions  of  the  Brain,  p.  171.     New  York,  1876. 

3  Text-book,  p.  684. 


DIRECTION   OF   SOUND.  611 

perceives  low  tones,  and  that  the  anterior  section  in  the  neigh- 
borhood of  the  fissure  of  Sylvius  is  for  the  perception  of  high 
tones. 


Determination  of  Direction  of  Sound. 

It  was  formerly  supposed  that  the  direction  of  sound  was 
determined  by  the  aid  of  the  semi-circular  canals.  It  seems, 
however,  from  clinical  experience,  that  the  direction  of  sounds 
is  determined  by  the  two  ears  acting  together,  for  many  pa- 
tients have  assured  me  that  simultaneously  with  the  loss  of  one 
ear,  they  have  lost  in  great  if  not  complete  measure,  the  ability 
to  tell  from  whence  sounds  came.  It  is  probable  that  the  two 
ears  are  not  necessary  for  the  determination  of  the  quality  of 
tones.  If  this  be  true,  there  is  no  advantage  in  binaural  stetho- 
scopes, other  than  that  which  may  be  gained  by  having  both 
ears  closed  to  distracting  external  sounds. 


CHAPTER  XXL 

DISEASES  OF  THE  INTEBNAL  EAE. 

Difficulty  in  Diagnosis. — Clinical  and  Pathological  Advances. — Differentiation  between 
Diseases  of  Middle  and  Internal  Ear. — Nervousness  and  Nervous  Deafness. — 
Symptoms  of  Primary  Disease  of  the  Cochlea. — Acoustic  Neuritis. — Atrophy  of 
the  Acoustic  Nerve. — Ca^es. — The  Tuning-Fork  in  Diagnosis. — Deafness  to  Cer- 
tain Tones. — Double  Hearing. — Electricity. — Syphilitic  Disease  of  the  Cochlea. — 
Cochlitis.  — Cases. 

WITH  our  present  knowledge,  any  discussion  of  the  diseases  of 
the  internal  ear,  is  based  upon  a  less  secure  foundation  of  patho- 
logical and  clinical  experience,  than  is  the  case  in  the  consid- 
eration of  diseases  of  the  external  and  middle  ear.  Until  the 
greater  questions  in  the  physiology  and  anatomy  of  the  laby- 
rinth are  positively  settled,  we  cannot  be  sure  of  our  classifica- 
tions of  disease.  But  the  great  barrier  to  our  accurate  knowl- 
edge of  diseases  of  the  labyrinth — such  a  knowledge  as  we  have 
in  studying  the  affections  of  the  optic  nerve  and  retina — is  found 
in  the  fact,  that  the  otoscope  as  yet  only  enables  us  to  see  the 
tympanum  and  mouth  of  the  Eustachian  tube,  while  the  oto- 
liths,  the  semi-circular  canals,  and  the  whorls  of  the  cochlea 
remain  hidden  by  an  apparently  impenetrable  bony  case.  In 
spite  of  all  this,  clinical  and  pathological  study,  are  slowly  giv- 
ing us  access  to  what  was  once  as  much  a  maze  to  the  thera- 
peutist, as  to  the  anatomist.  A  certain  class  of  diseases  of  the 
internal  ear,  can  now  be  made  out  with  as  much  accuracy  as 
diseases  of  the  heart,  lungs,  or  kidneys.  We  can,  in  some  in- 
stances, even  classify  the  diseases  of  the  semi-circular  canals 
and  cochlea,  for  some  of  them  are  to  be  plainly  distinguished. 

In  this  chapter,  then,  I  shall  endeavor  to  set  forth  in  a  simple 
manner,  how  we  may,  in  many  instances,  differentiate  between 
diseases  of  the  middle  and  internal  ear.  It  is  not  long  since  the 
average  description  of  diseases  of  the  tympanum  and  Eusta- 
chian tube,  assumed  that  they  belonged  to  the  internal  ear,  for 
all  the  parts  beyond  the  membrana  tympani  were  classified  as 
internal.  It  is  a  great  step  forward,  to  have  clearly  separated 
the  middle  ear  from  the  labyrinth,  the  real  internal  ear.  I  have 


PRIMARY   DISEASE   OF   AUDITORY    NERVE.  613 

no  doubt  that  before  many  years,  medical  science  will  as  clearly 
separate  the  diseases  of  the  two  parts  as  it  has  its  anatomy. 
There  is  much  to  be  gained  in  practice,  by  a  careful  considera- 
tion of  what  is  already  known  of  the  differential  diagnosis  of  the 
diseases  of  the  middle  and  internal  ear,  and  I  shall  attempt  to 
make  this  as  clear  as  my  experience  and  deductions  from  that 
experience,  will  permit.  I  wish  it  to  be  understood,  however, 
that  I  believe  we  are  but  in  the  infancy  of  our  knowledge  of  this 
subject.  Just  as  explorations  in  an  hitherto  scarcely  traversed 
country,  have  a  great  attraction  for  the  enthusiastic  traveller, 
so  I  believe,  will  the  medical  explorer  find  very  much  to  interest 
him  in  the  diagnosis  of  diseases  of  the  labyrinth  and  acoustic 
nerve,  for  this  field  is  the  ultima  Thule  of  aural  territory. 

The  affections  of  the  internal  ear  may  be  classified  in  a  gen- 
eral way,  as  follows  :  Primary  and  secondary  diseases.  The 
latter  class  has  been  somewhat  discussed  in  the  various  chap- 
ters on  "Diseases  of  the  External  and  Middle  Ear."  They  are 
generally  recognized,  and  do  not  often  excite  discussion.  I  will, 
however,  speak  of  some  of  their  symptoms  again  somewhat 
fully  in  this  chapter,  after  the  primary  affections  have  been 
studied. 

Primary  affections  of  the  auditory  nerve,  or  what  were  called 
cases  of  nervous  deafness,  were  at  one  time  supposed  to  be  very 
common.  This  was  chiefly  due  to  the  teachings  of  Kramer  and 
the  preceding  authors.  Wilde  and  Troltsch,  gave  us  more  cor- 
rect notions  as  to  the  relative  frequency  of  the  diseases  of  the 
central  apparatus,  and  proved  that  the  diseases  of  the  middle  ear 
were  more  common  than  those  of  the  labyrinth — that  so-called 
nervous  deafness  was  comparatively  rare. 

Clinical  experience  has,  however,  brought  me  more  and  more 
to  the  conviction,  that  the  rebound  from  the  ideas  of  Kramer,  who 
at  one  time  classified  the  majority  of  cases  of  aural  disease  under 
the  head  of  nervous  affections,  to  those  of  Wilde  and  Troltsch, 
the  latter  author  tracing  almost  all  cases  to  an  inflammation 
of  the  middle  ear,  has  been  excessive,  and  that  there  is  a  larger 
proportion  of  cases,  which  are  primarily  affections  of  the  laby- 
rinth than  has  generally  been  believed  by  the  profession  for  the 
past  twenty  years. 

Before  I  discuss  the  symptoms  and  causes  of  affections  of  the 
nerve  of  hearing,  a  few  words  may  be  proper,  as  to  what  in 
general  terms  is  understood  by  impairment  of  hearing,  depen- 
dent upon  disease  of  the  central  apparatus,  or  by  nervous  deaf- 
ness. 

When  a  patient  is  debilitated  and  unstrung,  unsteady  in  mus- 
cular movement,  anxious  and  despondent,  and  is  at  the  same 


614  NERVOUSNESS   AND   NERVOUS   DEAFNESS. 

time  affected  with  a  chronic  affection  of  the  middle  ear,  he  is 
often  supposed  to  have  a  nervous  disease  of  the  ear.  It  is  quite 
doubtful,  however,  if  in  such  cases  the  auditory  nerve  is  at  all 
affected.  There  are  certainly  no  symptoms  of  derangement  of 
the  auditory  nerve,  in  the  general  debility,  unsteadiness,  and 
anxiety  that  are  popularly  denominated  nervousness.  Affec- 
tions of  this  nerve  make  the  subjects  deaf,  and  sometimes  cause 
them  to  stagger  in  their  gait,  but  they  do  not  always  render  them 
nervous  or  unsteady  in  the  ordinary  acceptation  of  those  term's. 
Besides,  it  cannot  be  said  that  nervous  people  are  especially 
liable  to  deafness  from  lesions  of  the  labyrinth,  any  more  than 
they  are  to  atrophy  of  the  optic  nerve.  On  this  point  Mr.  Hin- 
ton '  says,  that  it  is  difficult  for  him  to  accept  debility,  nervous 
or  other,  as  a  cause  of  nervous  deafness.  He  has  not  found  that 
the  cases  of  deafness  which  appear  to  him  as  properly  classed 
among  the  nervous  ones,  occur  especially  in  the  debilitated. 

With  this  view  I  am  in  full  accord.  So-called  nervous  people 
are  not  especially  apt  to  have  a  disease  of  the  acoustic  nerve, 
but  their  impairment  of  hearing  often  depends  upon  chronic  in- 
flammations of  the  tympanum,  its  ossicles,  muscles,  and  lining 
membrane.  The  nervousness  in  some  instances  results  from  the 
distressing  tinnitus,  and  the  impairment  of  hearing,  for  there  is 
no  affliction  more  depressing  than  impairment  of  hearing.  There 
are,  however,  symptoms  more  or  less  objective,  that  enable  us 
to  diagnosticate  with  tolerable  exactness  a  disease  of  the  inter- 
nal ear.  It  is  not  wholly  an  undiscovered  country. 

PRIMARY  DISEASE  OF  THE  COCHLEA  OR  OF  THE  TRUNK  OF  THE 
ACOUSTIC  NERVE. 

There  is  one  symptom  of  this  affection  that  is  pathognomonic, 
and  that  is  absolute  deafness.  There  is  no  disease  of  the  exter- 
nal ear,  and  none  of  the  middle  ear,  I  think,  which  will  make  a 
patient  deaf  to  all  sounds.  No  matter  what  may  be  the  patho- 
logical condition,  how  firmly  the  auditory  canals  or  tympana 
may  be  plugged,  sounds  conducted  through  the  bones  will  still 
be  heard ;  but  when  the  cochlea  and  the  vestibule  with  their 
contents  are  destroyed,  no  vibrations  are  perceived,  and  absolute 
deafness  exists.  But  such  cases  are  very  rare.  There  are  very 
few  absolutely  deaf  persons  in  the  world.  Hence  this  pathog- 
nomonic symptom  is  seldom  observed.  When  it  is,  of  course  a 
diagnosis  is  easily  made.  But  the  labyrinth  may,  I  believe,  be 
invaded  by  disease,  and  even  the  terminal  filaments  of  the 


Nervous  Deafness.     Reprint  from  Guy's  Hospital'  Reports,  1867. 


PKIMAKY   DISEASE   OF   INTERNAL   EAR.  615 

nerve  in  the  cochlea,  or  the  nerve-trunk  itself  be  diseased,  and 
yet  very  considerable  hearing  remain.  Reasoning  by  analogy, 
this  would  appear  to  be  true,  for  we  may  have  even  advanced 
atrophy  of  the  optic  nerve  and  retina,  and  yet  a  fair  degree  of 
vision.  It  has  been  too  hastily  assumed,  I  think,  that  because 
considerable  hearing  power  remained,  therefore  the  cochlea  could 
not  be  invaded.  We  must  go  much  deeper  in  symptomatology 
than  absolute  deafness,  if  we  desire  to  find  the  causes  of  disease 
of  the  acoustic  nerve. 

1.  The  ability  to  hear   the  tuning-fork  better  and    longer 
through  the  air  than  through  the  bones  of  the  head,  is  a  symptom 
of  disease  of  some  part  of  the  labyrinth,  either  of  the  vestibule, 
the  cochlea,  or  acoustic  nerve.     But  this  symptom  is  not  pathog- 
nomonic  of  primary  disease  of  the  labyrinth.    It  is  always  found 
when  the  labyrinth  is  invaded,  but  in  many  instances  it  is  a 
temporary  phenomenon  dependent  upon  abnormal  pressure  ex- 
erted upon  the  labyrinth  by  the  ossicles  or  the  drum-head.    If  we 
add  to  the  above  symptom  the  word  constantly,  so  that  it  shall 
read,   the    ability   to   constantly  hear  the  tuning-fork  better 
through  the  air  than  through  the  bones,  we  shall  be  nearer  to 
a  definition  of  a  symptom  of  primary  disease  of  the  cochlea. 
Even  then  we  must  exclude  cases  where  the  pressure  has  become 
permanent,  and  where,  after  all,  the  disease  of  the  labyrinth  is 
secondary  to  one  of  the  stapes  bone,  or  other  part  of  the  tympa- 
num.    This  much  we  may  say,  however,  that  better  aerial  than 
bone  conduction  indicates   either  primary  or  secondary  disease 
of  the  central  apparatus  of  hearing. 

2.  The  ability  to  hear  better  in  a  quiet  place,  u-hen  all  dis- 
tracting noises  are  absent,  is  a  symptom  of  disease  of  the  laby- 
rinth.    It  must  be  taken,  however,   when  applied  to  primary 
disease,  with  the  same  limitations  as  to  constancy  as  the  test  by 
the  tuning-fork. 

3.  The  ability  to  hear  conversation  relatively  farther  than 
the  tick  of  a  watch,  is  also  a  symptom  of  disease  of  the  cochlea 
or  nerve.     These   symptoms,  namely  better  aerial  than  bone 
conduction,  better  hearing  in  a  quiet  place,  relatively  better 
capacity  to  hear  the  human  voice  than  the  tick  of  a  watch, 
when  found  grouped  together  in  the  same  patient,  to  my  mind 
unmistakably  stamp  the  case  as  one  of  disease  of  the  acoustic 
nerve.     It  will  be  observed  that  I  have  said  nothing  of  vertigo, 
of  double  hearing,  of  incapacity  to  hear  one's  own  voice,  which 
are  generally  considered  to  be  symptoms  of  disease  of  the  laby- 
rinth.   I  have  purposely  omitted  any  enumeration  of  these  more 
marked  symptoms  at  this  point,  for  I  would  like  to  impress 
upon  my  readers  my  belief  that  there  is  a  class  of  cases  of  affec- 


616      DIAGNOSIS   OF   PRIMARY    DISEASE   OF   INTERNAL   EAR. 

tions  of  the  cochlea,  or  vestibule,  or  trunk  of  acoustic  nerve, 
whether  of  one  or  of  all,  I  do  not  pretend  to  know,  which  have 
no  very  marked  symptoms,  such  as  absolute  deafness,  vertigo, 
or  double  hearing.  I  will  give  instances  of  these  in  this  chapter, 
and  will  lay  stress  upon  them,  for  these  cases,  if  I  am  right,  are 
constantly  mistaken  for  disease  of  the  middle  ear.  It  is  from  a 
long  series  of  investigations^  that  I  have  come  to  the  conclusion 
that  such  cases  are  more  common  than  has  been  before  believed. 

I  ought  also  to  say,  that  in  diseases  of  the  labyrinth,  noise 
not  only  impairs  the  hearing  power,  but  it  often  also  distresses 
and  annoys  the  patient,  whereas  persons  who  are  very  deaf 
from  disease  of  the  middle  ear,  are  delighted  when  they  can  be 
in  a  noise. 

To  repeat,  whenever  the  following  train  of  symptoms  occurs 
in  a  case  of  impairment  of  hearing,  I  believe  w.e  may  conclude, 
in  the  light  of  our  present  knowledge,  that  we  have  to  do  with 
disease  of  the  internal  ear. 

1.  Tuning-fork  C2   is  heard  better  through  the'air. 

2.  Hearing  is  better  in  a  quiet  place. 

3.  Conversation  is  heard  relatively  better  than  a  watch. 

4.  Noise  is  annoying  to  a  more  marked  degree  than  is  usual 
to  people  who  hear  well,  or  to  those  who  are  deaf  from  disease  of 
the  middle  ear. 

5.  Inflation  of  the  tympanum  renders  the  hearing  worse. 

To  make  a  clear  diagnosis  these  symptoms  must  exist  to- 
gether. I  will  not  deny  that  some  cases  with  this  chain  of  symp- 
toms, may  be  secondary  affections  of  the  sensory  apparatus, 
although  I  think  these  symptoms  generally  indicate  that  the 
primary  lesion  is  in  the  labyrinth.  It  is  no  proof  that  a  disease 
of  the  ear  is  situated  in  the  tympanum,  because  the  drum-head 
has  not  a  normal  appearance.  I  think  this  fact  has  been  lost 
sight  of,  and  that  occasionally  cases  of  disease  of  the  nerve  have 
been  put  down  to  the  middle  ear  simply  because  a  drum-head 
was  sunken  or  opaque.  How  few  so-called  normal  membrana 
tympani  are  to  be  found,  only  he  who  has  searched  for  them 
among  people  with  good  hearing  power,  can  certainly  know.  A 
disease  of  the  tympanum  in  childhood  may  leave  its  traces  upon 
the  membrana  tympani  without  sensibly  impairing  the  hearing 
power.  The  condition  of  the  ossicles  and  of  the  lining  of  the 
tympanum  have  the  most  to  do  with  determining  the  hearing 
power,  when  the  nerve  is  sound.  To  them  and  not  to  the  drum- 
head should  we  look  for  information  as  to  the  middle  ear.  Be- 
sides, changes  may  occur  in  the  drum-head,  secondarily  to  dis- 
ease of  the  membranous  labyrinth  and  trunk  of  the  acoustic 
nerve.  Disease  may  travel  outward  as  well  as  inward 


ACOUSTIC   NEURITIS   AND   ATROPHY.  617 

CASES  ILLUSTRATIVE  OF  PRIMARY  DISEASE  OF  THE  ACOUSTIC  NERVE 
ACOUSTIC  NEURITIS,   OR  ATROPHY  OF  THE  ACOUSTIC  NERVE. 

CASE  I.— I.  P.  H ,  aged  fifty-nine,  farmer.     Sent  by  Dr.  G.  W.  Holmes, 

April  26,  1880.  The  patient  thinks  he  has  been  growing  hard  of  hearing  for  a 
year.  The  son  (Dr.  H.)  believes  that  this  period  could  be  extended  back  to 
three  or  four  years.  He  has  some  tinnitus,  but  this  symptom  does  not  seem  to 
be  a  marked  one.  His  ears  have  never  received  any  treatment.  He  hears  the 
watch  E.  -£%,  L.  -£%  ;  my  voice,  in  a  room  fifty  feet  long,  twenty-five  feet.  The 
aerial  conduction  is  said  by  him  to  be  twice  as  loud  as  that  through  the  bones. 
He  has  large  auditory  canals.  Both  membrame  tympani  are  depressed.  The 
light  spots  are  fully  formed.  There  are  opacities  at  the  margin.  Common  air 
and  vapor  of  chloroform,  used  by  niy  attachment  to  Politzer's  bag,  redden  the 
drum-heads,  but  the  patient  does  not  feel  them  enter  the  drum,  nor  does  the 
hearing  improve  after  the  ears  are  inflated. 

The  points  in  favor  of  a  diagnosis  of  disease  of  some  part  of 
the  labyrinth  or  acoustic  nerve  in  this  case,  to  my  mind  are  : 

1.  The  lessened  conduction  by  bone. 

2.  The  fact  that  although  his  ears  have  never  before  been 
inflated,  no  improvement  results  from  forcing  air  into  the  tym- 
pana. 

3.  The  voice  is  heard  much  better  relatively  than  the  tick  of 
a  watch. 

Those  who  are  inclined  to  make  a  diagnosis  of  disease  of  the 
middle  ear  from  the  appearance  of  the  membrana  tympani 
alone,  will  perhaps  make  one  in  this  case. 

CASE  II.— Mr.  S ,  aged  forty  six,  sent  by  Dr.  E.  Dupuy,  October,  20, 1880. 

This  patient  is  a  large,  well-developed  man  of  great  intellectual  activity,  who  is 
engaged  in  great  enterprises  in  the  Western  States.  He  leads  a  very  irregular 
life,  eats  very  rapidly  and  very  much,  takes  long  journeys  very  often,  but  he  is 
not  intemperate  in  the  use  of  alcohol  or  tobacco.  He  began  to  have  attacks  of 
vertigo  and  nausea  five  years  ago,  so  that  he  would  be  obliged  to  lie  down  for 
hours.  He  had  to  lie  on  his  back  ;  could  not  turn  on  his  side  or  his  belly.  He 
thinks  he  observed  tinnitus  and  impairment  of  hearing  after  the  first  attack. 
Ever  since  his  hearing  power  has  been  variable.  He  hears  worse  in  a  -noise;  low 
tones  are  heard  best;  music  is  disagreeable.  He  has  no  pain  in  his  ears;  the  attacks 
of  vertigo  are  growing  less  frequent.  Has  a  sense  of  general  dizziness.  Some- 
times he  falls  in  the  street.  He  has  flatulent  dyspepsia.  He  never  has  had  any 
venereal  disease.  Says  he  lias  been  prescribed  for  by  "  twenty  aurists." 

For  the  watch  his  H.  D.  is  K.  /¥,  L.  /¥ ;  voice,  three  feet.  The  tuning-fork 
"C"  is  heard  on  the  teeth  "  slightly  ;  "  not  at  all  on  the  forehead,  nor  on  any 
point  of  the  skull,  except  on  the  tip  of  each  mastoid.  The  aerial  conduction  is 
much  better  than  the  bone  on  each  side.  His  pharynx  is  granular.  Both  mem- 
brane tympani  are  somewhat  depressed ;  they  are  not  of  good  color,  and  the 
light  spots  are  small.  The  air  enters  each  ear  by  Politzer's  method,  and  after 
inflation  the  H.  D.  on  the  left  side  is  ^  ;  before  it  was  -fa. 


618  ACOUSTIC    NEURITIS   AND   ATROPHY. 

This  I  believe  to  be  a  mixed  case,  that  is  to  say,  one  of  the 
middle  ear  and  of  the  labyrinth.  But  I  believe  the  disease  of  the 
middle  ear  to  be  of  slight  importance,  and  not  to  be  the  cause  of 
the  great  loss  of  hearing  and  the  head  symptoms.  In  this  case 
my  diagnosis  is  based  upon : 

1.  The  suddenness  of  the  symptoms. 

2.  The  fact  that  the  patient  hears  worse  in  a  noise. 

3.  That  he  hears  low  tones  best. 

4.  That  music  is  disagreeable  to  him. 

5.  And  that  the  aerial  is  better  than  the  bone  conduction. 
The  variableness  of  his  hearing  power,  which,  however,  is 

never  good,  as  I  found  by  several  careful  examinations,  is  due, 
I  think,  to  the  catarrh  of  the  tympanic  cavities  and  Eustachian 
tubes,  which  he  undoubtedly  has.  I  do  not  think  the  symptoms 
of  labyrinthine  pressure  are  secondary  to  those  of  the  middle 
ear,  because  he  has  submitted  at  various  times  to  anti-catarrhal 
treatment,  with  no  marked  benefit.  Speculation  as  to  the  path- 
ology of  the  lesion  of  the  acoustic  nerve  is  perhaps  useless  ;  yet 
I  cannot  but  suppose  that  in  this  case  either  an  inflammatory  or 
a  hemorrhagic  exudation  has  occurred.  There  is  no  record  that 
the  patient's  urine  was  examined.  I  think  it  was  with  a  nega- 
tive result.  A  regular  life  was  advised  for  the  patient,  but  this 
he  declined,  and  I  anticipate  that  I  shall  one  day  hear  that  he 
has  succumbed  to  central  disease. 

CASE  III.— J.  J.  Me ,  postal  agent,  aged  forty.  Sent  by  Dr.  Collins, 

March  11,  1881.  When  a  boy  suffered  from  tinnitus.  Until  one  year  and  a  half 
ago  heard  well.  Attention  was  called  to  his  impairment  of  healing  by  his 
friends.  Does  not  hear  as  well  on  the  railway  cars  as  other  people.  His  occupation 
keeps  him  on  the  railway  more  than  half  of  the  time.  It  is  worse  when  he  is 
tired ;  appears  to  be  in  good  health ;  never  has  had  venereal  disease ;  temperate. 
H.  D.,  E.  A,  L.  -A-. 

Voice,  about  one  foot  from  the  ear,  not  well  even  there. 

The  bone  conduction  is  somewhat  better  than  the  aerial  on  both  sides ;  both 
are  feeble. 

Membrana  tympani  of  right  side  is  hyperaemic ;  there  is  no  light  spot.  Left 
side  Mt.  is  pale,  and  there  is  no  light  spot ;  pharynx  normal. 

In  this  case,  there  is,  I  think,  disease  of  the  middle  and  in- 
ternal ears,  but  I  think  that  of  the  labyrinth  predominates,  on 
the  following  grounds  : 

1.  Inability  to  hear  better,  or  even  as  well  as  ordinarily,  in 
the  noise  of  a  railway  carriage. 

2.  Feeble  bone  and  aerial  conduction. 

3.  Absence  of  nasal  and  pharyngeal  symptoms. 

I  think  acoustic  neuritis  has  supervened  upon  a  chronic  non- 
suppurative  inflammation  of  the  middle  ear;  that  he  had  an 


ACOUSTIC   NEURITIS   AND   ATROPHY.  619 

affection  of  the  middle  ear  in  childhood  is  shown  by  the  testi- 
mony as  to  tinnitus,  and  the  appearance  of  the  drum-head. 

Then  again,  the  tuning-fork,  although  feebly  heard  through 
the  air  as  well  as  through  the  bones,  is  rather  better  heard 
through  the  bones  than  the  air.  But  that  he  had  serious  disease 
of  the  acoustic  nerve  is,  I  think,  indicated  by  the  fact  that  he  not 
only  did  not  hear  better  in  the  noise  of  a  railway  carriage  than 
when  in  an  ordinarily  quiet  place,  but  that  he  heard  worse  than 
people  in  general.  The  hypersemic  drum-head  unattended  by 
pain  indicates,  I  think,  hypersemia  of  the  whole  apparatus,  and 
I  would  classify  this  also  as  a  mixed  case,  but  one  in  which  the 
nerve  was  predominantly  and  chiefly  affected. 

CASE  IV. — J.  S ,  lawyer,  aged  fifty-eight.  Ten  years  ago  the  patient  ob- 
served that  he  could  not  hear  distinctly.  He  suffered  also  from  "catarrh."  He 
hears  no  better  in  a  car  or  carriage.  His  sense  of  taste  and  smell  are  defective. 
His  throat  and  nostrils  have  been  treated  a  great  deal,  but  he  grows  slowly 
worse.  His  hearing  distance  for  the  watch  is  ?™"e-d  on  each  side.  He  hears  con- 
versation very  well,  in  a  quiet  place,  when  it  is  addressed  to  him.  The  aerial 
conduction  is  better  than  that  through  the  bone  on  each  side.  Both  drum-heads 
are  opaque,  and  the  light  spots  are  small. 

CASE  V. — Mrs.  L.  X ,  aged  fifty-one.     Has  had  much  trouble  during  the 

last  year,  and  has  grown  very  "nervous."  She  also  suffers  from  tinnitus  aurium, 
but  she  does  not  consider  herself  hard  of  hearing,  for  she  hears  conversation 
easily.  Is  very  anxious,  fears  she  will  have  serioiis  head  trouble.  Hearing  dis- 
tance ?? y  on  the  right  side,  on  the  left  J-? .  Aerial  and  bone  conduction  are  about 

48  4  o 

the  same  on  the  right  side.  Aerial  louder  than  bone  on  the  left.  The  right 
auditory  canal  is  eczematous  to  a  slight  degree.  The  right  menibrana  tympaui 
is  opaque.  The  left  is  also,  and  there  is  a  small  light  spot.  The  pharynx  is 
normal.  The  patient  has  been  treated  through  the  nose  and  throat  without 
benefit. 

It  is  useless  to  multiply  these  cases.  They  are  not  rare, 
but  they  are  commonly  supposed  to  be  cases  of  catarrh  of  the 
middle  ear.  They  are,  I  believe,  actually  affections  of  the  acous- 
tic nerve  or  labyrinth.  What  their  nature  is,  more  exactly  than 
this,  I  cannot  say,  but  I  suspect  some  of  them  to  be  cases  of 
acoustic  neuritis,  and  that  they  finally  end  in  atrophic  changes. 
I  know  of  no  local  treatment  that  is  of  any  use.  What  may  be 
done  by  the  injections  of  pilocarpine  is  yet  to  be  shown.  Polit- 
zer  uses  a  two  per  cent,  solution  of  the  muriate  subcutaneously. 
He  injects  four  drops  of  this  solution  at  first,  and  gradually  in- 
creases the  dose  to  ten  drops  daily.  If  the  results  are  no  better 
than  those  obtained  by  the  hypodermic  injection  of  strychnia 
in  atrophy  of  the  optic  nerve,  not  much  is  to  be  expected  from 
the  remedy.  Yet  the  prognosis  in  this  class  of  cases  is  not  so 


620  PKESBYKOUSIS — ABSOLUTE   DEAFNESS. 

bad  as  in  a  slowly  advancing  case  of  catarrh  or  of  proliferous 
inflammation  of  the  middle  ear.  The  disease  generally  occurs 
after  middle  life,  and  I  think  many  of  the  patients  preserve  the 
power  to  hear  conversation  addressed  specially  to  them,  lectures, 
sermons,  and  so  forth,  up  to  an  advanced  age.  They  hear  badly 
in  a  theatre,  however,  where  the  dialogue  is  animated.  Persons 
who,  after  middle  life,  lose  much  of  their  hearing  from  dis- 
ease of  the  tympanum  and  Eustachian  tube,  soon  become  un- 
able to  hear  conversation,  and  are  much  more  disabled  than 
those  who  suffer  from  chronic  acoustic  neuritis  or  atrophy.  It  is 
possible  that  there  is  a  failure  of  the  power  of  the  tensor  tym- 
pani  and  of  the  stapedius  muscle  in  advancing  life,  which  ren- 
ders it  impossible  to  properly  regulate  or  focus,  so  to  speak,  the 
sound  image  upon  the  terminal  apparatus.  In  such  cases  the 
patient's  hearing  for  his  range,  is  as  good  as  that  of  those  with 
active  muscles,  and  young  crystalline  lenses.  There  may  be  in- 
deed a  presbykousis  as  well  as  a  presbyopia,  but  these  cases  may 
be  distinguished  from  those  I  am  attempting  to  describe. 

Treatment. — The  treatment  of  acoustic  neuritis,  or  atrophy 
of  the  chronic  form,  should  be  based  upon  the  general  condition 
and  habits  of  the  patient.  Care  and  worry,  indigestion,  the 
menopause  in  women,  will  often  be  found  to  be  at  the  origin  of 
them,  and  no  special  treatment  can  be  undertaken  until  each 
case  is  studied  by  itself.  But  inflation  of  the  ears  and  active 
treatment  by  the  Eustachian  tube,  invariably  make  these  people 
worse,  and  such  means  are  to  be  strictly  avoided. 

POSITIVE    SYMPTOMS  OP  DISEASE  OF   THE  LABYRINTH. 

From  the  report  of  recent  cases  treated  by  the  muriate  of  pi- 
locarpine,  I  am  greatly  inclined  to  give  this  drug  a  further  trial. 
I  am  also  disposed  to  hope  for  something  from  it  in  cases  of  dis- 
ease of  the  middle  and  internal  ear,  from  the  very  good  results 
I  have  had  from  its  use  in  choroiditis.  It  is  best  used  hypoder- 
mically,  using  six  to  ten  minims  of  a  two  per  cent,  solution  at 
bedtime.  It  is  necessary  to  produce  considerable  diaphoresis 
and  to  continue  the  treatment,  occasionally  allowing  interrup- 
tions of  two  or  three  days,  for  four  weeks. 

When  absolute  deafness  exists,  we  certainly  have  disease  of 
the  acoustic  nerve.  We  may,  it  is  true,  have  mere  impairment 
of  the  hearing,  and  yet  find  disease  of  the  labyrinth  ;  but  if  the 
deafness  is  absolute,  or  nearly  so,  we  must  conclude  that  the  es- 
sential part  of  the  organ  of  hearing  is  invaded.  It  is  a  very  rare 
thing,  indeed,  that  the  impairment  of  hearing  from  disease  of 
the  middle  ear  becomes  so  profound  that  words  spoken  into  the 


THE  TUNING-FORK.  621 

ear  through  a^tube  cannot  be  distinguished ;  but  in  many  of  the 
cases  of  deafness  from  cerebro-spinal  meningitis,  from  fevers 
from  apoplexy  of  the  labyrinth,  from  injuries,  no  words,  how- 
ever conducted  to  the  ear,  can  be  made  out  by  the  patient,  he 
cannot  hear  his  own  voice,  and  total  deafness,  not  merely  great 
impairment  of  hearing,  exists.  The  auditory  nerve  may  have 
some  perception  of  sound  in  these  latter  cases  ;  but  these  per- 
ceptions can  only  be  compared  to  the  flashes  of  light  seen  by 
amaurotic  patients. 

This  is  in  accordance  or  in  analogy  with  what  we  observe  in 
diseases  of  the  eye.  When  absolute  blindness  occurs,  we  know 
that  we  are  dealing  with  an  affection  of  the  central  or  percep- 
tive apparatus.  Opacities  of  the  cornea,  cataract,  iritis,  do  not 
destroy  the  perception  of  light.  This  is  only  done  by  diseases 
of  the  retina,  optic  nerve,  or  brain. 

SYMPTOMS    OF    DISEASE    OF    THE    MIDDLE    EAR    AND    LABYRINTH. 

Other  symptoms  of  disease  of  the  internal  ear,  such  as  ver- 
tigo, nausea,  vomiting,  tinnitus  aurium,  double  hearing,  are 
also  seen  in  affections  of  the  middle  ear,  when  the  nerve  expan- 
sion in  the  labyrinth  is  involved  by  undue  pressure.  A  stagger- 
ing gait,  or  loss  of  equilibrium,  is  also  a  symptom  of  disease  of 
the  internal  ear,  and  especially  of  the  semicircular  canals.  But 
even  when  this  symptom  occurs,  it  is  not  possible  to  determine 
from  it  alone  whether  the  disease  of  the  internal  ear  is  a  pri- 
mary or  secondary  affection. 


THE   TUNING-FORK 


As  I  have  repeatedly  said,  the  tuning-fork  is  very  valuable  as 
a  means  of  diagnosis  in  suspected  nerve-deafness.  As  we  have 
seen  in  the  second  chapter,  the  tuning-fork  is  heard  more  dis- 
tinctly if  the  ear  be  stopped  with  the  finger  or  the  like,  while 
the  hand  is  placed  upon  the  forehead  or  teeth.  If  a  person  be 
affected  with  disease  of  the  internal  ear,  it  is  a  clinical  fact  that 
such  a  stoppage  of  the  meatus  does  not  usually  at  all  intensify 
the  sound  of  the  tuning-fork.  Besides,  if  one  acoustic  nerve  be 
diseased,  while  the  other  is  sound,  or  if  one  be  affected  much 
more  than  the  other,  the  tuning-fork  is  heard  more  distinctly  on 
the  sound  or  better  side,  just  the  contrary  from  what  is  found  in 
disease  of  the  middle  ear. 

If  a  tuning-fork  (pitched  in  bass  C)  be  placed  on  the  vertex 
or  on  the  mastoid  process,  and  allowed  to  vibrate  until  the  notes 
are  no  longer  heard,  and  its  prongs  be  then  brought  close  to  the 
ear,  if  the  ear  be  normal  the  tone  will  be  heard  again, 
called  Renne's  positive  experiment.     According  to  Lucae,  in 


622  THE  TUNING-FORK. 

those  cases  of  impairment  of  hearing,  where  the  fork  is  heard 
again  after  having  ceased  to  be  heard  on  the  vertex  or  mastoid, 
when  placed  close  to  the  ear,  there  is  disease  of  the  internal  ear. 
When  it  is  not  heard  again  there  is  disease  of  the  external  or 
middle  ear.  I  have  had  some  experience  with  this  test,  and  I 
believe  it  to  be  a  good  one.  But  like  many  other  methods  of 
using  the  tuning-fork  for  a  differential  diagnosis,  when  em- 
ployed alone,  it  is  not  sufficient  to  enable  us  to  speak  positively 
as  to  its  diagnostic  value. 

At  my  suggestion,  Dr.  J.  B.  Emerson,  Surgeon  to  the  Man- 
hattan Eye  and  Ear  Hospital,1  undertook  the  examination  of 
persons  with  normal  hearing  power,  by  means  of  the  tuning- 
fork.  The  results  he  obtained  are  a  positive  contribution  to  the 
subject.  It  is  to  the  tuning-fork  that  I  think  we  must  look  as 
yet,  for  that  much-to-be-desired  means  of  making  a  diagnosis 
between  a  chronic  affection  of  the  middle  ear  and  a  similar  one 
of  the  acoustic  nerve.  Fifty  persons  with  normal  hearing  were 
carefully  chosen  from  a  hundred,  said  to  have  normal  hearing. 
Two  forks  were  used,  one  32£  ctm.  long,  with  cylindrical  prongs 
and  handle  giving  a  note  more  than  an  octave  below  the  middle 
C.  C1  =  264  double  vibrations.  This  tuning-fork  is  called  "A," 
in  Dr.  Emerson's  tests. 

Another  fork,  about  17  ctm.  long,  with  rectangular  prongs 
and  conical  handle,  giving  a  note  one  octave  above  middle  C, 
and  called  "C*"  —  528  vibrations. 

The  average  duration  of  time  in  seconds  during  which  these 
forks  were  heard  is  shown  by  the  following  table.  The  table 
was  made  up  from  fifty  cases  of  persons  who  had  no  disease  of 
the  ears. 

"  In  every  case  the  A  fork  was  louder  when  heard  through 
bone,  and  the  Ca  fork,  when  heard  through  air. 

"  The  average  duration  in  seconds  was  as  follows  : 

"  A  fork- 
Air  conduction   31 

Bone  conduction 18 

Excess  in  air  conduction 13 

"C2     fork- 
Air  conduction 36 

Bone  conduction 16 

Excess  in  air  conduction 20 

"  A  and  C2  forks- 
Air  conduction 34 

Bone  conduction 17 

Excess  in  air  conduction  . .  .17 


1  The  complete  paper  will  be  found  in  the  Archives  of  Otology,  Vol.  XII.,  p.  03. 


THE  TUNING-FORK.  623 

"  A  and  C 3  are  both  heard  longer  through  aerial  than  through 
bone  conduction. 

"  The  difference  between  air  and  bone  conduction  is  less  for 
the  A  note  than  for  the  C3  note  ;  A  being  heard  about  1.75  times 
longer  through  air  than  through  bone;  while  C"  was  heard 
about  2.25  times  longer  through  air  than  through  bone. 

"  For  both  A  and  Ca,  the  average  duration  is  twice  as  long 
through  the  air  as  it  is  through  the  bone." 

Dr.  Emerson  also  examined  fifty  persons  suffering  from  dis- 
ease of  the  middle  ear,  with  the  same  tuning-fork,  and  he  con- 
cludes as  follows  : 

1st.  Relying  on  the  statements  of  patients  in  regard  to  the 
loudness  of  tuning-forks,  as  a  test  in  ear  troubles,  will  lead  to 
error  unless  account  is  taken  of  the  fork  used.  As  a  rule,  in 
normal  ears  high  notes  are  heard  louder  through  aerial  con- 
duction, and  low  notes  louder  through  bone  conduction.  This 
is  true  also,  to  a  limited  extent,  in  diseased  ears,  as  verified  by 
the  thirty-nine  cases  cited. 

2d.  The  relative  duration  of  aerial  and  bone  conduction  is  a 
better  test.  In  normal  ears,  in  all  cases  the  tuning-fork  is  heard 
longer  through  air  than  through  bone,  the  proportion  being 
greater  for  high  than  low  notes ;  and  for  the  middle  C  (C")  it 
should  be  heard  about  twice  as  long  through  air  as  through 
bone,  the  average  duration  in  my  cases  being  for  bone  seven- 
teen seconds,  and  for  air  thirty-four  seconds.  Any  marked  de- 
parture from  this  indicates  disease. 

3d.  In  external-  or  middle-ear  disease  this  proportion  is  re- 
duced, and  in  well-marked  cases  the  average  bone  conduction 
remaining  the  same  or  being  increased,  the  aerial  conduction 
will  be  reduced  until  it  becomes  equal  to,  or  much  less  than,  bone 
conduction.  In  one  hundred  ears  tested,  the  average  duration 
was  for  bone  seventeen  seconds,  for  air  thirteen  seconds,  or  1.3 
longer  through  bone  than  air.  This  reduction  obtained  also  in 
the  thirty-nine  cases  in  which  air  conduction  was  louder  than 
bone,  the  average  duration  in  those  ears  being  equal. 

4th.  When  the  bone  conduction  is  longer  than  aerial  conduc- 
tion, and  yet  much  less  than  the  average  duration  of  bone  con- 
duction for  normal  ears,  it  is  an  indication  not  only  of  middle-ear 
trouble,  but  that  the  nervous  apparatus  is  involved. 

5th.  If  the  proportion  between  bone  and  air  remain  the  same, 
and  the  hearing  power  much  lowered,  it  is  probably  an  indica- 
tion of  disease  of  the  internal  ear.  Air  conduction  markedly 
exceeding  bone  conduction,  the  bone  conduction  may  be  entirely 
lost,  and  yet  air  conduction  continue  to  a  limited  extent. 

The  two  following  cases  illustrate  this  : 


624  DEAFNESS   TO   CERTAIN  TONES. 

CASE  I.— Mr. ,  aged  forty-five.  Chronic  alcoholism.   H.  D.,  Right  ear,  -4a«  ; 

A  tuning-fork  heard  louder  through  bone,  C*  louder  through  air ;  duration  of  A 
tuning-fork  through  air,  thirty  seconds  ;  duration  of  C-,  forty-five  seconds ;  dura- 
tion of  A  through  bone,  twenty  seconds,  of  C'2  through  bone,  twenty-five  seconds. 
Left  ear,  -/„- ;  A  tuning-fork  heard  louder  through  bone,  C'3  heard  louder  through 
air  ;  duration  of  A  through  air,  thirty  seconds,  of  C2  through  air,  forty  seconds  ; 
duration  of  A  through  bone,  fifteen  seconds,  of  C5  through  bone,  fifteen  seconds. 

CASE  II. — Mr. ,  aged  twenty-three.    Meningitis.  H.  D.,  Eight  ear,  -& ;  A 

heard  louder  through  bone,  C'2  through  air  ;  duration  of  A  through  air,  ten  sec- 
onds, of  C'2  through  air,  twenty-five  seconds  ;  duration  of  A  through  bone,  three 
seconds,  of  C2  through  bone,  five  seconds.  Left  ear,  -fa  ;  A  heard  louder  through 
bone,  C'2  through  air  ;  duration  of  A  through  air,  ten  seconds,  of  C2  through  air, 
twenty-five  seconds ;  duration  of  A  through  bone,  five  seconds,  of  C'2,  ten  seconds. 

It  is  from  experiments  such  as  these,  and  long  experience 
with  patients,  that  I  have  come  to  the  conclusion  that  the  best 
method  we  have  of  diagnosticating  or  of  assisting  in  the  diag- 
nosis of  doubtful  cases  of  disease  of  the  internal  ear,  is  the  tun- 
ing-fork "  C2,"  generally  known  as  *'  C,"  the  second  one  described 
in  Dr.  Emerson's  tests.  If  the  tuning-fork  "Ca"  be  heard  louder 
and  longer  through  the  air  when  placed  near  the  ear,  than  it  is 
when  placed  on  the  mastoid  process,  we  probably  have  a  disease 
of  the  nerve,  while  if  it  be  heard  better  through  the  bone,  we 
have  disease  of  the  middle  or  external  ear.  For  the  sake  of 
brevity,  we  may  say,  if,  in  cases  of  impaired  hearing,  aerial 
conduction  be  better  and  longer  than  bone  conduction,  we  have 
disease  of  the  internal  ear.  If  bone  conduction,  be  better  than 
aerial,  there  is  disease  of  the  middle  or  external  ear. 

The  test  with  musical  tones  of  various  heights  is  of  impor- 
tance in  detecting  partial  defects  in  hearing  tones,  but  it  cannot 
be  relied  upon  as  an  exclusive  test,  as  some  authors  are  disposed 
to  make  it. 

Galton's  whistle  is  a  good  means  of  testing  the  capacity  for 
hearing  high  or  low  tones. 

In  some  cases  of  disease  of  the  middle  ear,  of  one  side,  the 
aerial  conduction  disappears  entirely,  and  the  conduction  through 
the  bones  is  so  intensified  by  the  blocking  up  of  the  tympanum 
and  the  rigidity  of  the  ossicles,  that  when  the  tuning-fork  is 
placed  upon  any  of  the  bones  of  the  skull,  even  upon  the  mastoid 
of  the  sound  side,  its  vibrations  seem  to  the  patient  to  proceed 
from  the  diseased  ear. 

DEAFNESS  TO  CERTAIN  TONES. 

If  Helmholtz  be  correct  in  his  theories,  deafness  to  certain 
tones  must  of  necessity  be  due  to  some  affection  of  the  cochlea, 
and  this  is  an  affection  sometimes  seen,  as  has  been  known 
since  the  experiments  of  Wollaston,  who  found  that  some  per- 


DOUBLE  HEARING.  625 

sons  were  unable  to  hear  the  chirping  of  a  cricket,  which  is  the 
highest  tone  known.  If  we  accept  the  theory  of  Helmholtz, 
that  Corti's  organ  in  the  labyrinth  is  a  resonance  apparatus,  and 
that  individual  fibres  of  the  auditory  nerve  in  the  cochlea  are 
tuned  for  certain  notes,  the  pathology  of  such  cases  becomes 
clear.  It  should  be  remembered,  however,  that  this  symptom, 
as  well  as  double  hearing,  like  tinnitus  aurium,  may  be  merely 
secondary  to  an  affection  of  the  middle  ear,  which  causes  press- 
ure upon  and  hypersemia  of  the  cochlea. 

DOUBLE  HEARING. 

One  of  the  first,  if  not  the  first,  accounts  of  this  phenomenon, 
is  by  Sir  Everard  Home,  who  described  it  in  an  article  on  "  The 
Membrana  Tympani."  l  His  case  was  that  of  "  a  music  master" 
who  perceived  a  confusion  of  sounds  in  his  ears  after  catching 
cold.  He  discovered  that  the  pitch  of  one  ear  was  half  a  note 
lower  than  that  of  the  other  ;  and  that  the  perception  of  a  single 
sound  did  not  reach  both  ears  at  the  same  instant,  but  seemed 
as  two  distinct  sounds  following  each  other  in  quick  succession, 
the  last  being  the  lowest  and  weakest. 

Mr.  Home  naively  remarks  that  "  this  complaint  distressed 
him  for  a  long  time,  but  he  recovered  from  it  without  any  medical 
aid."  This  was  a  case  of  true  double  hearing,  corresponding 
fairly  well  to  double  vision.  Since  then  cases  have  been  reported 
by  Gruber,"  Moos,'  Knapp,4  S.  M.  Burnett,6  myself,  and  others. 
In  Knapp's  case  the  patient  heard  all  tones  of  the  middle  octave 
of  a  piano  two  tones  higher  than  in  the  sound  ear.  The  ear 
was  affected  with  suppuration  of  the  tympanum.  Burnett's  case 
was  also  that  of  a  professor  of  music,  who  observed  that  an  A 
tuning-fork,  when  held  before  the  right  ear,  sounded  from  f  to  £  a 
tone  flat.  Ten  years  after  he  observed  that  the  same  fork,  when 
held  before  the  same  ear,  sounded  one  tone  higher.  His  hearing 
distance  was  TV  for  the  watch,  and  the  membraiia  tympani  was 
healthy  in  appearance.  This  patient  seems  to  have  been  unable 
to  detect  this  false  hearing  of  one  ear,  unless  he  held  a  tuning- 
fork  before  the  meatus.  It  was  consequently  rather  a  curious 
phenomenon  than  a  source  of  annoyance  to  the  subject  of  it. 

It  will  be  observed  that  the  cases  of  Home  and  Knapp  are  in- 
stances of  true  double  hearing — that  is,  two  distinct  sounds  were 
heard  simultaneously,  one  true  and  the  other  false.  This  is  dip- 
lakousis,  to  which  the  addition  of  an  adjective,  binauralis,  is 

1  Transactions  of  the  Royal  Society,  1800.  J  Lehrbuch,  p.  626. 

3  Klinik  der  Ohrenkrankheiten,  p.  319. 

4  Transactions  of  the  American  Otological  Society,  1871. 

5  Archives  of  Ophthalmology  and  Otology,  vol.  v. ,  p.  527. 

40 


626  CASES    OF   DOUBLE   HEARING. 

only  confusing.  Burnett's  case  is  one  of  false  hearing.  When  the 
true  notes  are  heard  and  then  a  false  one,  or  when  the  last  notes 
are  repeated  or  echoed,  we  should  speak  of  echo-hearing. 

Double  hearing  and  echo-hearing  exist  very  often  as  symptoms 
of  pressure  upon  the  labyrinth  from  disease  of  the  middle  ear, 
or  possibly  from  independent  disease  of  the  labyrinth,  but  such 
symptoms  are  generally  complained  of  only  by  people  of  good 
musical  education,  and  affect  only  the  higher  notes  of  the  scale. 

Sometimes  the  same  condition  prevails  in  both  ears,  and  all 
notes  are  heard  false.  This  should  also  be  called  echo-hearing. 

In  1877  I  saw  and  treated,  for  a  short  time,  a  patient  who 
presented  the  following  curious  phenomena  of  hearing :  With 
the  right  ear  he  can  hear  the  high  notes  of  a  piano  better  than 
the  low  ones  ;  in  walking  on  the  sea-shore  he  hears  the  crickets 
in  the  grass,  but  not  the  roar  of  the  waves ;  he  can  hear  the 
chirping  of  insects  and  the  movements  of  their  bodies  easily  ;  the 
tick  of  a  watch  is  heard  normally,  f-f ,  and  yet  he  cannot  hear 
the  tones  of  the  human  voice  at  all  well.  With  the  left  ear, 
whose  hearing  distance  for  the  watch  is  but  ^,  the  power  of 
hearing  conversation  is  so  good  that  the  patient,  a  young  man 
of  seventeen,  carries  on  his  studies  at  college  with  no  particular 
difficulty. 

Acute  Suppuration  of  Right  Middle  Ear — Hypercemia  of  Labyrinth  of  Same 

Side — True  Double  Hearing. — P.  A.  S ,  aged  twenty-five;  pianist.     October 

18, 1875.  Seen  with  Dr.  E.  G.  Loring.  This  patient  is  suffering  from  an  acute  in- 
flammation of  the  right  middle  ear,  presenting  the  usual  symptoms,  but  he  also 
presents  the  phenomenon  of  so-called  double  hearing.  In  striking  any  musical 
instrument — piano,  organ,  or  violin — he  hears  the  half-note  above  in  addition  to 
the  one  struck.  He  hears  both  notes  together.  The  false  note  gradually  dies  out, 
leaving  finally  only  the  sound  of  the  note  struck.  He  observes  this  when  both 
ears  are  open,  and  when  the  sound  one  is  closed.  He  has  never  tried  closing 
the  diseased  ear.  This  phenomenon  lasted  about  three  weeks.  It  disappeared 
gradually,  the  false  note  being  nearer  and  nearer  to  the  true  one,  until  it  finally 
blended  with  it. 

At  my  request  this  patient  sent  me  an  account  of  his  case, 
which  is  here  reproduced. 

About  the  year  1851  (when  only  one  year  old),  I  was  taken  sick,  and  I  ailed 
for  about  twelve  or  fourteen  months,  but  I  recovered.  As  long  as  I  can  re- 
member back,  I  complained  of  my  hearing ;  the  left  ear  was  all  right,  but  it 
seemed  to  me  that  I  could  have  done  just  as  well  without  the  right ;  hearing 
with  one  and  hearing  with  both  was  all  the  same  thing. 

My  parents  took  me  to  a  physician,  who  cleaned  and  syringed  it  for  me,  but 
nothing  else  was  done  to  it.  When  I  was  about  six  years  (that  is,  after  this 
physician  had  cleaned  it),  it  began  to  discharge  a  little.  It  really  did  stop  run- 
ning, but  the  hearing  never  improved.  I  studied  music,  and  could  always  boast 


CASES   OF  DOUBLE  HEAKINGK  627 

of  as  true  an  ear  as  any  musician  could  wish  for.  In  the  autumn  of  1874  I  went 
to  Germany  to  improve  myself  further  in  my  profession,  and  one  morning,  sit- 
ting in  a  Leipzig  Gewandhaus-Concert  (this  was  in  January),  I  felt  a  tickling  in 
the  defected  ear,  and  to  my  surprise  it  had  discharged  again.  I  went  at  once 

to  Dr.  M ,  who  told  me,  "  the  drum  of  the  ear  was  almost  gone,  and  it  had 

been  an  old  complaint,  but  the  running  he  could  stop  easily."  He  gave  me 
some  ear-drops,  which  had  no  effect  on  it  at  all.  Then  I  had  no  pain.  In  July 
I  returned  to  America.  In  August  (the  month  after)  I  experienced  the  first 
pains ;  the  inside,  the  whole  frame  and  cheek-bone  felt  as  if  it  would  split.  That 
time  I  came  under  the  treatment  of  Dr.  Loring,  who  then  told  me,  "  the  drum 
was  entirely  gone."  He  stopped  the  pain,  and  the  running  also  diminished,  and 
I  had  good  hopes  of  its  being  well  soon.  I  kept  on  syringing  with  warm  water 
and  putting  in  ALUM,  SODA,  SALT,  NITRATE  OF  SILVER,  etc. ,  as  the  Doctor  saw  fit  to 
use.  One  day  in  December,  1875,  the  same  old  pain  (which  had  kept  me  awake 
many  a  night)  came  back  again,  and  to  my  astonishment  found  that  my  hearing 
was  affected  in  the  most  alarming  manner.  Any  sound  that  struck  the  ear  felt 
as  if  I  had  got  a  box  on  the  ear,  but  what  most  frightened  me  was  that  I  heard 
incorrectly.  For  instance,  when  I  struck  C  on  the  piano,  I  would  hear  this  very 
C;  but  in  addition  I  heard  the  C  sharp,  which  is  just  half  a  note  above.  Now 
imagine  my  confusion ;  by  striking  the  common  chord  of  C  (C,  E,  G),  I  not  only 
heard  this,  but  at  the  same  time  C£,  E£,  Gil  being  the  common  chord  of  CJJ. 
I  feared  very  much  I  would  have  to  give  up  my  profession  and  take  hold  of 
some  other  occupation,  which,  I  believe,  would  have  been  enough  to  drive  me 
crazy. 

At  first  these  two  notes  (or  chords)  would  sound  about  equally  loud  and 
keep  sounding  wrong  until  both  died  away,  but  after  a  week  or  so  this  wrong 
note  C5  would  sound  like  a  perfect  Ctj  only  at  the  instant  of  the  key  of  C  be- 
ing struck,  but  gradually  as  the  sound  diminished  and  the  vibrations  became 
fewer,  this  Cfi  would  get  lower  until,  when  the  note  became  quite  faint,  I  would 
at  last  hear  nothing'  but  the  true  C. 

Playing  on  an  organ  this  would  not  be  the  case,  as  the  sound  cannot  be 
diminished  in  the  same  way  as  on  the  piano  ;  there  I  would  hear  the  wrong 
note,  Cj>,  with  the  right  one,  C,  as  long  as  the  sound  could  be  heard. 

On  the  violin  it  was  worse  yet  (from  the  reason,  I  suppose,  of  its  being  nearer 
the  head,  and  the  notes  being  more  acute).  I  could  not  for  the  space  of  four 
weeks  play  the  violin  at  all,  as  I  knew  not  when  I  played  right  or  wrong,  for  on 
that  instrument  the  wrong  note  C>  predominated  the  one  I  should  only  have 
heard  (C)  by  far.  The  C  indeed  sounded  very  faint.  If  anybody  else  played 
the  violin,  the  wrong  notes  would  not  predominate  quite  so  much. 

With  my  own  voice  it  was  worse  yet.  If  I  played  on  the  piano  I  could  tell 
what  notes  I  ought  to  have  heard,  but  in  singing  I  had  no  idea  how  near  I  sang 
the  right  note.  So  everything  sounded  double  and  confused. 

The  first  time  I  became  aware  of  this  bad  state  was  at  an  evening  service  at 
St.  Luke's  Hospital,  where  I  played  the  organ.  After  service  I  told  some  one 
that  the  people  had  sung  most  awfully  out  of  tune  and  something  must  also  be 
wrong  with  the  organ,  when  I  was  answered  that  the- music  had  never  sounded 
better.  So  playing  on  my  piano,  I  found  that  my  own  hearing  was  the  sole 
cause  of  these  discords.  I  remained  in  this  state  for  about  two  weeks.  Then 


628  ECHO   HEARING. 

instead  of  hearing  a  note  with  the  additional  HALF  A  TONE  higher  (C  and  C£),  I 
heard  C  and  a  note  between  C  and  C^l  (this  tone  cannot  be  produced  on  keyed 
instruments,  only  on  strings) ;  after  a  few  days  more  the  wrong  note  got  to  be 
nearer  the  right  one,  yet  (perhaps  $  above,  and  by  and  by  -,Lb-  above)  still  I  heard 
both  instantaneously.  The  harder  I  struck  a  key  or  note,  the  louder  would  the 
additional  wrong  one  sound,  but  the  better  the  ear  got,  the  purer  and  clearer 
would  my  hearing  be.  At  the  end  of  about  five  weeks  this  haunting  false  note 
was  quite  gone,  and  ever  after  that  I  heard  only  the  note  I  struck  and  nothing 
else,  and  now  I  attend  to  my  profession,  as  well  and  cheerful  as  I  can  wish  for. 

Deafness  from  Chronic  Suppuration,  Left  Ear ;  Impacted  Wax,  Right  Ear — 

Echo  Hearing  with  One  Ear. — Miss  L ,  aged  twenty.  Had  a  discharge  from 

left  ear  a  long  time  ago,  and  has  been  deaf  on  that  side  since.  Had  a  great 
deal  of  earache  when  small.  Noticed  impaired  hearing  in  right  ear  about  three 
weeks  ago.  Slight  tinnitus  at  times,  but  no  pain  or  discharge.  No  cause 
assigned.  Since  right  ear  has  become  deaf,  she  has  been  annoyed  by  "  a  dis- 
agreeable vibration  like  an  echo  "  in  her  right  ear,  after  singing  a  high  note  or 
hearing  another  do  so.  Has  not  noticed  it  in  instrumental  music.  Does  not 
sing  herself  higher  than  F  or  G. 

H.  D.— E.,  iS,  L.,  A. 

Hears  a  whisper  twenty  feet  with  ease.  Piano-test  gives  a  negative  result. 
Pharynx  looks  well.  Has  some  impacted  wax  in  both  auditory  canals.  Drum- 
heads are  opaque.  After  removing  wax  and  inflating  ears,  H.  D.  became — R. , 
5o,  L-,  4o"-  The  echo  disappeared  on  the  same  day,  and  two  months  after  had  not 
returned. 

It  is  hardly  necessary  to  more  than  allude  to  the  symptom  of 
tinnitus  aurium  in  primary  disease  of  the  labyrinth.  It  scarcely 
differs  from  the  sounds  heard  by  those  who  suffer  from  chronic 
non-suppurative  inflammation,  although  in  many  cases  of  total 
deafness  no  tinnitus  exists,  and,  so  far  as  my  observation  ex- 
tends, tinnitus  aurium  is  more  frequent  and  disturbing  in  chronic 
disease  of  the  middle  ear,  than  in  chronic  affections  of  the  laby- 
rinth. 

PAIN  AND  SENSITIVENESS  TO  SOUNDS. 

Pain  is  a  marked  symptom  of  acute  inflammation  of  the  mem- 
branous labyrinth.  All  affections  of  the  acoustic  nerve  are, 
however,  generally  accompanied  by  extreme  sensitiveness  of 
the  ear  to  loud,  jarring,  discordant,  or  even  ordinary  sounds.  It 
is  then  necessary  to  keep  the  patient  in  a  very  quiet  place.  I 
have  several  times  been  compelled  to  order  the  patient  away 
from  the  city  to  the  quiet  of  the  country.  In  all  cases  of  this 
kind  the  auditory  canal  should  be  protected  by  plugs  of  cotton. 
Nausea,  vomiting,  and  convulsions,  as  well  as  opisthotonos  and 
delirium,  may  be  symptoms  of  labyrinth  disease,  as  well  as  of 
cerebro-spinal  meningitis  and  of  acute  catarrh  of  the  middle  ear. 


PRIMARY    INFLAMMATION    OF    LABYRINTH.  629 

I 

Voltolini  is  quite  positive  that  there  is  a  primary  affection  of 
the  labyrinth  that  is  sometimes  mistaken  for  cerebro-spinal  men- 
ingitis, and  he  has  written  several  papers,1  illustrated  by  cases, 
to  sustain  his  position.  Although  his  ideas  have  been  rejected 
by  some  other  writers,  I  do  hot  think  the  question  can  be  at  all 
considered  as  a  settled  one.  After  a  careful  consideration  of  the 
history  of  very  many  cases  of  supposed  cerebro-spinal  meningitis 
occurring  in  young  children,  there  is  at  least  a  strong  suspicion 
in  my  mind  that  Yoltolini  is  correct  in  this  view,  and  that  an 
affection  of  the  labyrinth  may  occur  in  young  children,  and  be 
erroneously  supposed  to  be  cerebro-spinal  meningitis.  I  have 
had  very  few  opportunities  of  studying  cases  of  cerebro-spinal 
meningitis,  although  I  have  seen  a  large  number  of  deaf  persons 
in  whom  the  loss  of  hearing  was  said,  upon  good  professional 
authority,  to  have  occurred  during  the  course  of  this  disease.  It 
is  very  much  to  be  desired,  for  the  clearing  up  of  some  points  in 
the  nature  of  this  disease  and  its  relations  to  the  acoustic  nerve 
and  internal  ear,  that  those  who  are  accustomed  to  examine  and 
treat  cases  of  aural  disease  should  have  opportunities  of  seeing 
cases  of  cerebro-spinal  meningitis  in  their  acute  stages.  The 
bonds  between  specialism  and  general  practice  should  be  very 
close,  if  real  advance  in  this  or  in  other  directions  is  to  be 
made. 

The  symptoms  of  that  form  of  inflammation  of  the  membran- 
ous labyrinth  that  has  been  mistaken  for  cerebro-spinal  menin- 
gitis, should  be  carefully  considered  in  order  that  the  practitioner 
may  be  able  to  clear  up  the  doubts  which  have  been  thrown  upon 
the  existence  of  this  disease.  Gruber,2  and  Schwartze  unite  with 
me  in  believing  that  such  a  disease  may  occur.  If  we  find  a 
child  suddenly  taken  with  severe  vomiting,  which  is  followed  by 
stupor  or  delirium,  without  paralysis,  and  with  but  slight  opis- 
thotonos,  such  as  children  have  with  acute  otitis  media,  and 
if  we  see  this  child  recover  in  a  few  days,  except  that  it  is 
absolutely  deaf,  and  walks  with  a  staggering  gait,  I  think  it  is 
more  reasonable  to  think  of  an  affection  of  the  ear  as  the 
cause  of  these  symptoms,  than  of  a  disease  of  the  brain  and 
spinal  cord. 

Having  seen  many  cases  in  which  such  a  history  was  clearly 
given,  I  must  believe  in  a  primary  acute  inflammation  of  the 
labyrinth,  and  I  trust  the  attention  of  physicians  will  be  directed 
to  the  differential  diagnosis  between  this  affection  and  cerebro- 
spinal  meningitis. 


1  Monatsschrift  fur  Ohrenheilkunde,  Bd.  I.  and  VI. 
s  Lehrbucli,  p.  552. 


630  SYPHILITIC   COCHLITIS. 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  INTERNAL  EAR  BY  THE  MEANS  OF 

ELECTRICITY. 

In  the  former  editions  of  this  work  considerable  space  was 
given  to  this  subject,  but  I  have  become  convinced  that  the  con- 
clusions of  those  who  believe  they  were  able  to  diagnosticate 
disease  of  the  labyrinth  by  means  of  the  galvanic  current,  are 
fallacious.  I  do  not  think  it  has  yet  been  demonstrated  that  we 
determine  the  situation  or  character  of  a  lesion  in  the  ear,  by 
means  of  electricity,  and  I  do  not  advise  the  student  of  aural 
disease  to  concern  himself  with  the  various  theories  upon  the 
subject. 

I  will  now  discuss  some  of  the  well  known  causes  of  primary 
disease  of  the  labyrinth. 

DISEASE  OF  THE  COCHLEA  (COCHLITIS)  FROM  SYPHILIS. 

Syphilitic  affections  of  the  middle  ear  are  perhaps  more  com- 
mon than  those  of  the  labyrinth.  For  example,  in  the  course  of 
the  earlier  symptoms,  among  which  is  pharyngitis,  and  so  forth, 
we  often  have  tubal  and  tympanic  catarrh,  which  is  not  to  be  dis- 
tinguished from  an  aural  catarrh  arising  in  the  course  of  an- 
other disease,  so  far  as  the  ear  is  concerned.  There  may  be  also 
in  the  course  of  the  later  periods  of  the  disease,  a  syphilitic  exu» 
dation  into  the  tympanum,  and  about  the  ossicles.  There  is, 
however,  a  disease  of  the  labyrinth  and  acoustic  nerve  occurring 
in  syphilis.  This  disease  has  some  characteristics  of  its  own. 
It  is  analogous  to  certain  forms  of  what  are  known  as  brain  or 
nerve  syphilis,  such  for  example  as  lesions  of  the  ocular  motor 
nerves,  and  the  medulla.  I  have  given  it  the  name  of  syphilitic 
cochlitis,  simply  because  it  seems  plain  to  me  that  it  is  as  well 
defined,  as  being  chiefly  a  disease  of  the  cochlea,  as  are  certain 
affections  of  the  semi-circular  canals  of  the  optic  nerve  and 
retina.  The  cases  of  diseases  of  the  ear  in  inherited  syphilis, 
which  I  have  had  the  opportunity  of  studying,  seem  to  me  to  be 
chiefly  diseases  of  the  peripheric  and  not  of  the  central  part  of 
the  organ  of  hearing.  Just  as  we  have  disease  of  the  cornea 
and  iris  as  the  more  frequent  lesions  of  the  eye  in  congenital 
syphilis,  so  do  we  have  tubal  and  tympanic  catarrh,  originat- 
ing from  the  snuffles  in  infantile  and  congenital  syphilis. 

Mi*.  Hutchinson '  is  of  the  opinion  that  all  the  cases  of  aural 
disease  occurring  in  the  course  of  inherited  syphilis,  which  he 


1  A  Clinical  Memoir  on  Certain  Diseases  of  the  Eye  and  Ear,  consequent  on  Inher- 
ited Syphilis,  p.  182.     London,  1863. 


SYPHILITIC   DISEASE   OF  LABYRINTH.  631 

inspected,  are  "due  either  to  disease  of  the  nerve  itself  or  to 
.  some  change  in  non-accessible  parts  of  the  auditory  apparatus. " 
I  think  that  Mr.  Hutchinson  has  not  attached  enough  import- 
ance to  the  throat  symptoms  in  his  cases,  and  that  thus  he  has 
been  led  to  give  diseases  of  the  labyrinth  an  undue  preponder- 
ance in  aural  affections  resulting  from  syphilis.  The  fact  that 
the  Eustachian  tubes  are  "  pervious  "  goes  but  a  very  little  way 
to  sustain  the  theory  of  labyrinth  disease,  and  Mr.  Hutchinson 
admits  that  his  cases  showed  changes  in  the  membrana  tympani, 
but  not  "adequate"  ones.  After  or  during  the  course  of  the 
snuffles  of  syphilitic  children,  we  are  very  sure  to  have  catarrh 
of  the  middle  ear.  The  following  case  illustrates  the  difficulty 
of  making  a  positive  differential  diagnosis  between  middle  ear 
and  labyrinth  disease  in  the  existence  of  a  syphilitic  diathesis  : 

Acute  Pain  in  Right  Side  of  Head  along  the  Course  of  the  Fifth  Nerve,  followed 
by  Impairment  of  Hearing  and  Tinnitus  Aurium — Gradual  Loss  of  Hearing  more 
marked  on  the  Right  Side — Primary  Syphilis  One  Year  since  followed  by  Mucous 

Patches  and  Erythema. — Mr.  X ,  aged  twenty-nine,  May  26,  1873,  was  sent  to 

me  for  advice,  by  Dr.  E.  Hubbard,  of  Bridgeport,  Conn.  The  following  history 
was  given  by  Dr.  Hubbard  and  the  patient :  One  year  ago  he  had  a  chancre  in 
the  urethra,  followed  by  mucous  patches  and  erythema.  He  was  treated  by  the 
use  of  mercury  and  iodide  of  potassium,  and  recovered  very  rapidly  from  those 
symptoms.  About  five  weeks  ago  the  patient  was  seized  with  a  severe  pain  in 
the  track  of  the  fifth  nerve,  with  tinnitus  aurium.  The  tinnitus  was  compared 
by  the  patient  to  the  peep  of  a  chicken,  although  this  variety  of  noise  was  not 
the  only  one  observed.  There  was  no  pain  in  the  ear  itself.  The  general  health 
is  excellent.  The  hearing  had  gradually  diminished  in  the  right  ear  since  the 
pain  and  tinnitus  occurred.  The  pain  subsided  in  a  short  time ;  the  tinnitus 
still  continues.  The  hearing  distance  is — R.,  ^sge-d;  L.,  1|.  The  tuning-fork  is. 
heard  more  distinctly  in  the  better  ear.  When  the  right  ear  is  closed  by  the 
finger,  however,  the  tuning-fork  is  heard  better  in  that  ear.  The  mernbrame 
tympani  of  both  sides  are  sunken,  that  of  the  left  more  so.  The  light  spot  is 
nearly  obliterated  on  the  right  side.  There  is  a  small  one  on  the  left.  Inflation 
of  the  ears  by  Politzer's  method  improves  the  hearing  a  very  little  on  each  side. 
The  pharynx  is  secreting  excessively. 

I  suppose  this  to  be  a  case  of  sub-acute  catarrh  of  the  middle 
ear,  with  a  secondary  affection  of  the  labyrinth.  The  tuning- 
fork  indicates  that  there  is  labyrinth  disease,  and  yet  the  test  is 
not  positive,  because,  when  the  right  ear  was  closed,  the  sound 
of  the  fork  was  intensified  on  the  side  of  the  closed  ear.  The 
appearances  of  the  drum-head,  and  of  the  pharynx,  as  well  as 
the  results  from  the  employment  of  Politzer's  method,  are,  how- 
ever, positive  proofs  that  some  catarrh  of  the  middle  ear  exists. 
The  patient  is  under  treatment,  both  constitutional  and  local. 

Mr.  Hutchinson  speaks  only  of  hereditary  syphilis  in  his  book, 


632  SYPHILITIC    COCHLITIS. 

but  there  is  the  same  tendency  to  catarrh  of  the  pharynx  and 
Eustachian  tubes  in  inherited  syphilis  as  in  any  other  form. 

There  are  cases,  however,  of  disease  of  the  ear  occurring  as  a 
result  of  syphilis,  when  all  the  marked  symptoms  are  derived 
from  the  labyrinth.  If  diagnosticated  at  all  early  in  their  course, 
they  are  susceptible  of  relief  and  cure  by  the  free  use  of  mercury 
and  iodide  of  potassium.  My  recent  experience  has  been  in  such 
gratifying  contrast  to  that  which  I  had  had  when  the  first  edi- 
tion of  this  book  was  published,  that  I  am  very  glad  to  report  it 
for  the  purpose  of  illustrating  what  has  just  been  said.  In  the 
cases  now  about  to  be  quoted,  I  think  we  are  perhaps  justified 
in  going  a  little  farther  in  our  classification  than  merely  to  state 
that  there  is  disease  of  the  labyrinth.  We  may,  perhaps,  diag- 
nosticate disease  of  the  cochlea,  or  at  least  say  that  the  affection 
of  the  cochlea  is  predominant  in  certain  cases,  just  as  we  may 
speak  of  disease  of  the  semi-circular  canals,  when  vertigo  and 
staggering  are  the  predominant  symptoms.  Syphilitic  cochlitis 
may  perhaps  be  a  proper  name  for  this  class  of  cases. 

Before  quoting  the  cases  in  question,  I  will  tabulate  certain 
conclusions  which  afford  a  guide  to  the  determination  of  the 
situation  and  character  of  the  lesion  where  there  is  a  doubt. 

1.  Disease  of  the  cochlea,  as  of  the  other  parts  of  the  laby- 
rinth, usually,  although  not  always,  manifests  itself  suddenly. 
The  patient  can  definitely  fix  upon  a  time  when  he  became  deaf, 
and  when  he  began  to  have  tinnitus  aurium.     This  is  true  even 
when  one  side  only  is  affected.     The  one-sided  deafness  would 
not  be  so  quickly  recognized  were  it  not  usually  accompanied  by 
tinnitus,  vertigo,  and  often  by  unsteadiness  of  gait.     Sudden 
loss  of  hearing  and  the  sudden  occurrence  of  tinnitus,  vertigo, 
and  staggering,  are  not,  however,  entirely  peculiar  to  labyrinth 
disease,  since  it  is  well  known  that  we  sometimes,  although 
rarely,  have  the  same  symptoms  in  cases  of  inspissated  cerumen 
and  catarrh  of  the  middle  ear.     They  are  therefore  only  of  path- 
ognomonic  value  in  connection  with  the  objective  examination 
and  tests. 

2.  The  tuning-fork  C"  is  heard  more  distinctly  through  the 
air  than  through  the  bones. 

3.  The  examination  of  the  membrana  tympani  and  the  em- 
ployment of  the  methods  for  inflating  the  middle  ear.  will  usu- 
ally give  us  reasonable  conclusions  as  to  the  situation  of  a  given 
disease  of  the  ear,  so  that  at  the  least  we  may  exclude  collec- 
tions of  fluid  in  the  tympanic  cavity  in  making  a  differential 
diagnosis  between  disease  of  the  middle  ear  and  of  the  laby- 
rinth. 

4.  The  piano,  or  any  very  similar  musical  instrument,  will 


SYPHILIS   OF   THE  LABYRINTH.  633 

aid  us  in  determining  whether  or  not  disease  of  the  cochlea  ex- 
ists. The  examination  of  cases  that  were  unquestionably  affec- 
tions of  the  labyrinth  shows  that  the  power  of  appreciating  low 
tones  is  the  last  to  suffer,  and  the  first  to  recover  in  most  cases 
of  disease  of  this  part  of  the  ear,  so  that  these  will  be  heard 
when  the  high  ones  are  either  not  heard  at  all,  or  are  heard 
4 'false"  or  doubled.  From  our  present  knowledge  of  the  phys- 
iology of  hearing,  when  these  symptoms  are  present,  we  must 
conclude  that  the  cochlea  is  the  seat  of  disease,  even  if  it  be 
secondarily  affected. 

5.  The  diagnosis  of  syphilis  of  the  labyrinth  depends  in  a 
great  measure  upon  the  same  kind  of  evidence  as  that  from 
which  we  conclude  that  a  case  of  optic  neuritis  or  choroiditis  is 
syphilitic ;  that  is  to  say,  the  history  and  the  presence  of  other 
symptoms  such  as  an  eruption,  mucous  patches,  etc.  It  should 
not  be  forgotten,  however,  that  the  occurrence  of  labyrinth  dis- 
ease, in  a  person  who  has  probably  had  the  initial  lesion  of 
syphilis,  even  if  no  other  symptoms  are  present,  is  a  very  sus- 
picious circumstance,  which  should  lead  to  a  careful  weighing 
of  the  indications  for  and  against  a  mercurial  treatment. 

I  prefer  to  say  disease  of  the  cochlea,  instead  of  disease  of 
the  labyrinth,  when  the  prominent  symptoms,  as  in  the  cases 
now  reported,  are  great  impairment  of  hearing,  the  inability  to 
hear  certain  tones,  and  the  production  of  false  ones.  These  are 
evidences,  I  think,  of  cochlear  disease,  whatever  else  we  may 
have.  Tinnitus  is  a  symptom  common  to  many  forms  of  aural 
affections,  while  vertigo  and  unsteadiness  of  gait  are  chiefly  to 
be  referred  to  undue  pressure  from  the  base  of  the  stapes  upon 
the  semi-circular  canals,  and  not  to  disease  of  the  cochlea.  I 
think  too  much  stress  has  been  laid  upon  increased  pressure 
upon  this  latter-named  part  of  the  ear,  to  the  neglect  of  disease 
having  its  origin  in  the  tone-perceiving  apparatus — the  cochlea. 
"Meniere's  disease  "has  always  seemed  tome  an  unfortunate 
name,  since  it  has  been  indiscriminately  applied.  It  ought  not 
to  be  used  unless  it  refers  to  a  case  such  as  that  in  which  a  hem- 
orrhage  into  the  semi-circular  canals  was  found.  Of  late,  cases 
in  which  the  cochlear  symptoms  are,  at  least,  the  predominant 
ones,  are  sometimes  styled  cases  of  "Meniere's  disease,"  when 
they  have  very  little  in  common  with  cases  of  hemorrhage.  It 
is  interesting  to  notice  that  we  are  always  assisted  in  a  diag- 
nosis of  supposed  cochlear  disease,  if  the  patient  have  a  musical 
education.  I  believe  all  the  cases  of  double  hearing  that  have 
been  reported  occurred  in  persons  enjoying  a  musical  training. 
Certainly  other  patients  have  had  the  same  symptoms,  but  they 
have  been  unable  to  appreciate  them.  The  power  of  hearing 


634  SYPHILIS    OF   THE   LABYRINTH. 

certain  tones  can,  however,  be  accurately  tested  in  all  patients 
except  young  children. 

The  pathological  investigations  of  syphilis  of  the  internal  ear 
have  not  been  numerous,  but  we  are  not  entirely  without  them. 
Moos  '  reported  a  case  of  secondary  syphilis,  in  which  deafness, 
annoying  tinnitus  aurium,  and  osteocopic  pains  in  the  skull  were 
complained  of.  The  hearing  was  rapidly  destroyed.  Death. 
At  the  autopsy  the  right  external  and  middle  ear  were  found 
intact,  sclerosis  of  the  petrous  portion  of  the  temporal  bone, 
periostitis  in  the  vestibule  and  small-celled  infiltration  of  the 
membranous  labyrinth,  anchylosis  of  the  stapes  to  the  fenestra 
ovalis.  Trunk  of  the  acusticus  unchanged. 

Gruber  has  also  reported  a  similar  case.2  Grubers  patient 
died  of  typhus  fever.  A  post-mortem  examination  of  the  ear 
showed  vascular  injection  of  a  high  degree  in  the  soft  tissues  of 
the  labyrinth  as  well  as  thickness  of  these  parts,  in  connection 
with  marked  hypersemia  of  the  mucous  membrane  of  the  tym- 
panum. The  patient,  who  was  syphilitic,  and  who  had  been 
very  slightly  hard  of  hearing  at  times  from  catarrh  of  the 
tympanum,  became  suddenly  absolutely  deaf,  with  occasional 
attacks  of  vertigo  when  he  first  became  deaf.  The  vertigo 
disappeared,  but  the  deafness  remained. 

I  have  never  believed  that  the  affection  which  I  have  de- 
nominated cochlitis  involved  the  cochlea  solely,  but  that  it 
affected  that  part  of  the  ear  predominantly,  just  as  a  patient 
may  have  severe  hypersemia,  and  even  inflammation  of  the 
external  auditory  canal,  quite  secondary  to  the  main  trouble  in 
the  middle  ear. 

It  would  be  very  convenient  indeed,  if  we  could  separate 
diseased  parts  from  each  other  by  a  line  as  distinct  as  that 
in  facial  erysipelas,  or,  to  use  a  geographical  comparison,  as 
marked  as  the  separation  of  Mexico  from  the  United  States  by 
the  Rio  Grande ;  but  to  give  the  exact  line  of  demarcation  in 
disease  is  very  often  impossible.  It  must  be  named  from  the 
.predominance  of  the  symptom  in  certain  parts  or  organs. 

CASES. 

CASE  I. — Sudden  Loss  of  Hearing  and  Tinnitus — Primary  Syphilis — Alopecia- 
Eruption — Anti-syphilitic  Treatment — Cure. — W.  M ,  aged  thirty-seven.  The 

patient  states  that  five  weeks  ago,  on  one  particular  day,  he  observed  that  his 
hearing  was  impaired  and  that  he  had  a  noise  in  his  ears.  From  that  time  to 
this  he  has  grown  worse.  He  also  states  that  his  hearing  is  worse  at  night. 

1  Medical  Record,  from  Centralblatt  ftir  Chirurgie,  August  19,  1877,  from  Vir- 
chow's  Archives.  2  Lehrbuch,  p.  617. 


CASES   OF   SYPHILITIC   COCHLITIS.  635 

About  six  months  ago  he  had  a  chancre ;  three  months  later  he  had  alopecia ; 
and  there  is  now  a  copper-colored  papular  eruption  upon  his  wrists  and  arms. 

Hearing  distance:  B.,  ^;  L.,  ^. 

The  tuning-fork  is  heard  better  in  the  left  ear.  The  pharynx  is  granular  and 
in  a  hypersecretive  condition.  The  drum-heads  both  show  small  light  spots. 
The  usual  treatment  for  catarrh  of  the  middle  ears  has  been  employed  since  the 
attack  of  tinnitus  and  the  loss  of  hearing,  but  without  success. 

The  patient  was. immediately  placed  upon  anti-syphilitic  treatment,  which  he 
carried  out  with  but  moderate  faithfulness,  but  he  began  at  once  to  improve. 
Two  months  after  his  tinnitus  was  relieved,  and  the  hearing  distance  was:  B., 
pr|8«.d.  L ^  ^  After  this  he  went  under  the  care  of  Dr.  Sturgis  for  other  symp- 
toms of  syphilis,  and  he  informed  me  that  he  heard  very  well. 

CASE  II. — Syphilitic  Ulcer  on  Os  Uteri — Loss  of  Hearing — Alopecia-Eruption — 

Recovery. — Mrs.  X ,  aged  thirty-one.  April  8,  1875.  Seven  weeks  ago  this 

patient,  who  was  brought  to  me  by  her  husband,  a  physicia'n,  began  to  observe 
an  impairment  of  hearing,  accompanied  by  a  dull  pain  and  by  tinnitus. 

Hearing  distance:  B.,  it ;  L.,  -fa. 

The  husband,  and  the  note  of  a  physician  who  had  supervised  the  treatment 
of  the  patient,  state  that  she  had  not  been  well  since  the  birth  of  her  child  in 
August  last,  when  an  abrasion  (syphilitic?)  was  found  on  the  os  uteri.  This,  the 
husband  says,  was  probably  produced  by  infection  from  his  own  finger,  upon 
which  was  the  initial  lesion  of  syphilis,  contracted  in  attending  a  case  of  labor  in 
a  syphilitic  patient. 

The  symptoms  from  which  Mrs.  X suffered  before  the  loss  of  hearing 

were  neuralgic  pains  about  the  eyes,  hypersemia  of  the  optic  disks,  papular  erup- 
tion on  the  chest,  and  alopecia.  There  are  now  traces  of  the  eruption,  and  the 
patient  has  a  poor  appetite,  pains  in  her  legs,  and  some  neuralgia  about  the 
eyes.  The  treatment  was  anti-syphilitic  in  the  beginning,  but  has  not  been  very 
thoroughly  carried  out  of  late.  The  pharynx  is  granular,  and  the  left  drum  has 
no  light  spot.  The  usual  treatment  for  catarrh  of  the  middle  ears  has  been  pur- 
sued to  some  extent,  but  with  no  benefit,  for  the  aural  symptoms  are  increasing. 

A  thorough  anti-syphilitic  treatment  was  undertaken,  and,  according  to  a 
note  from  the  husband  and  a  verbal  communication  from  the  physician  who  first 
observed  the  case,  the  patient  progressed  steadily  to  recovery  under  this  manage- 
ment. No  local  treatment  was  used  after  the  case  was  seen  by  me.  I  hardly 
think  general  treatment  would  have  been  sufficient  had  the  tympanic  disease  been 
predominant. 

CASE  III. — Venereal  Sore — Loss  of  Hearing — Vertigo — Double  Hearing — Re- 
covery.— Mr.  U ,  aged  thirty-three.  August  30,  1876.  The  patient  states 

that  toward  the  end  of  last  June  he  observed  dulness  of  hearing  and  tinnitus  in 
both  ears.  Soon  after  he  discovered  that  he  was  totally  deaf  as  to  the  left  ear, 
and  the  right  ear  has  been  gradually  growing  worse. 

On  August  1st  he  began  to  have  attacks  of  vertigo  and  staggering,  and  has 
had  several  since.  He  had  a  venereal  sore  on  his  penis  about  February  15th, 
and  says  he  had  mucous  patches  in  his  mouth  and  throat  about  the  middle  of 
March. 

Hearing  distance:  B.,  •&;  L.,  -4%. 

He  hears  words  when  spoken  distinctly  into  the  right  ear.     The  drum-heads 


636  SYPHILITIC   COCHLITIS — CASES. 

are  both  dull  in  color  and  have  no  light  spots.  The  air  enters  both  tympanic 
cavities  freely  upon  the  employment  of  Politzer's  method,  and  reddens  the  drum- 
heads, but  causes  no  improvement  in  hearing. 

A  diagnosis  of  syphilitic  disease  of  the  labyrinth  on  both  sides  was  made  by 
my  associate,  Dr.  E.  T.  Ely,  who  saw  him  first ;  and  after  the  patient  had  seen 
Dr.  E.  L.  Keyes  in  consultation,  he  was  put  upon  a  course  of  inunction  with  the 
oleate  of  mercury,  mercurial  baths,  and  iodide  of  potassium  internally,  in  steadily 
increasing  doses. 

On  September  9th  he  was  already  better.  He  could  hear  the  voice  much 
better ;  the  attacks  of  vertigo  continued,  but  there  was  no  more  staggering. 

A  more  complete  examination  showed  some  peculiar  symptoms  which  throw 
some  light  upon  disease  of  the  cochlea,  and  which  are  therefore  now  detailed. 
The  noises  of  the  street  jar  the  patient's  head  very  unpleasantly.  He  cannot 
distinguish  sibilants — s  sounds  like/,  etc.  The  notes  of  the  piano  become  dis- 
cordant at  fifth  C.  They  do  not  so^nd  double,  "but  false.  In  the  higher  notes 
the  seventh  note  sounds  more  like  the  octave  than  the  octave  itself. 

September  12th. — There  is  a  little  more  improvement  in  the  hearing.  He 
hears  notes  truly  about  an  octave  higher  than  on  the  9th.  When  an  upper  note 
is  struck  he  also  hears  with  this  the  half  note  above.  He  still  complains  of  the 
unpleasant  effect  of  the  noisy  streets.  The  drugs  have  been  steadily  continued, 
and  with  no  unpleasant  effects.  He  is  allowed  to  leave  New  York  and  go  to  the 
sea-side. 

September  19th. — Patient  now  hears  conversation  with  the  right  ear  at  ten 
feet.  The  left  ear  seems  to  have  no  power  whatever.  The  dose  of  potash  has 
now  reached  seventy-five  grains  three  times  a  day. 

October  5th. — Hears  the  voice  at  twenty  feet  with  ease.  All  but  the  last  two 
notes  of  the  piano  are  heard  correctly.  In  words  /  still  sounds  like  .s.  Is  taking 
one  hundred  and  twenty  grains  potash  at.  a  dose  three  times  a  day.  The  patient 
fully  recovered  his  hearing  power  for  ordinary  conversation,  and  resumed  his 
profession.  The  recovery  was  confined  to  the  right  ear. 

It  is  possible  that  we  have  not  paid  enough  attention  to  the 
protection  of  inflamed  or  hyperaemic  ears.  Boiler-makers  may 
protect  their  ears  from  the  destructive  hyperaemia  caused  by  the 
concussions  to  which  their  work  exposes  them,  by  plugging  the 
meatus ;  and  telegraph-operators  may  suffer  from  an  impair- 
ment of  hearing  induced  by  exposure  to  the  continuous  clicking 
of  a  telegraph  instrument.  In  the  case  just  reported,  the  patient 
experienced  great  relief  from  the  change  of  residence  from  near 
the  noisy  pavements  of  New  York  to  the  quiet  of  the  sea-side  ; 
and  I  believe  where  noise  produces  such  a  degree  of  irritation  as 
was  complained  of  in  this  case,  we  should  carefully  select  a  resi- 
dence for  the  patient  with  a  view  to  keeping  him  out  of  noise. 
In  ophthalmic  therapeutics  a  great  deal  of  care  is  often  necessary 
to  protect  the  eyes  from  the  light ;  and  in  acute  aural  disease, 
and  perhaps  in  some  forms  of  chronic  affections,  the  same  care 
should  be  exercised  lest  the  ears  be  exposed  to  loud  or  continu- 
ous sounds. 


SYPHILITIC   COCHLITIS — CASES.  637 

CASE  IV.  is  one  that  I  saw  at  the  Manhattan  Eye  and  Ear  Hospital,  through 
Dr.  E.  T.  Ely,  who  had  charge  of  the  patient  at  the  Eastern  Dispensary,  and 

who  diagnosticated  disease  of  the  labyrinth.  Mr.  L ,  aged  twenty-two. 

September  7,  1876.  Complains  that  two  days  ago  he  was  suddenly  attacked  by 
complete  deafness  in  the  left  ear,  accompanied  by  noises  like  "the  blowing  off 
of  steam."  These  symptoms  have  continued,  and  he  has  also  had  slight  vertigo 
and  feeling  of  unsteadiness — most  troublesome  when  he  turns  his  face  upward. 
He  had  a  venereal  sore  on  his  penis  two  years  ago,  and  subsequently  sore  mouth, 
falling  of  his  hair,  and  iritis.  Was  treated  for  syphilis  by  reputable  physicians. 

Hearing  distance :  E.,  4$;  L.,  -4V  Tuning-fork  heard  only  on  the  right  side. 
Drum-heads  somewhat  sunken,  with  dull  color  and  dull  light  spot.  Air  enters 
middle  ears  readily  through  Eustachian  tubes,  but  it  does  not  improve  the 
hearing. 

September  20th. — Patient  has  been  treated  for  catarrh  of  the  middle  ears, 
without  any  benefit.  Anti-syphilitic  treatment  was  advised  at  his  first  visit,  but 
he  has  refused  it  thus  far. 

The  diagnosis  in  this  case  has  not  been  subjected  to  the  cru- 
cial test  of  treatment.  Its  syphilitic  character  cannot  therefore 
be  so  strongly  emphasized.  Yet  when  a  history  of  general  syphi- 
lis is  so  distinct  and  a  labyrinth  affection  occurs,  I  think  we  may 
safely  conclude  that  the  latter  is  at  least  modified  by  the  venereal 
poison,  if  not  actually  caused  by  it. 

CASE  V. — Syphilis — Sudden  Deafness  and  Tinnitus — Symptoms  of  Disease  of 

Cochlea — Benefit  from  Treatment. — Mr.  S ,  aged  twenty-eight.  First  seen 

March  24,  1877,  with  the  following  history :  About  one  month  ago  he  noticed 
deafness  and  tinnitus  in  the  right  ear,  and,  a  few  days  later,  in  the  left.  Is  not 
sure  but  that  both  sides  were  affected  at  the  same  time.  Trouble  advanced 
rapidly,  and  in  three  weeks  he  was  so  deaf  that  he  ' '  couldn't  hear  anything  but 
loud  noises."  Never  had  any  pain  or  discharge.  Tinnitus  at  first  was  "like 
somebody  tapping  on  a  tumbler ; "  now  it  resembles  "the  wind  blowing."  Had 
some  dizziness  and  nausea  when  first  attacked.  Never  vomited.  Never  has 
noticed  any  unsteadiness  of  gait.  Has  no  vertigo  now,  except  when  he  runs  or 
takes  a  very  long  stride  in  walking.  Hearing  is  worse  in  a  noisy  place.  Thinks 
he  hears  low  notes  better  than  high  ones. 

Had  a  chancre  eighteen  months  ago.  Gives  no  history  of  any  secondary 
symptoms,  except  of  "sores  in  his  mouth."  Has  taken  mercury  and  iodide  of 
potash  since  a  week  after  his  aural  trouble  began,  but  without  benefit. 

Thinks  he  took  cold  a  few  days  before  his  deafness  began,  as  he  had  "a 
stiffness  "  of  his  neck  and  shoulders. 

H.  D. :  R.,  4^;  L.,  ^.  Loud  voice  one  foot  behind  back.  Hears  words, 
through  speaking-tube,  in  each  ear.  Hears  all  notes  of  piano,  but  does  not 
appreciate  difference  between  low  and  high  ones  correctly. 

Tuning-fork  heard  better  on  right  side.  Pharynx  looks  well.  Has  ulcera- 
tions  on  edges  of  tongue ;  Eustachian  tubes  pervious ;  no  effect  from  inflation. 
Right  drum-head  pinkish,  good  light  spot ;  left  drum-head  looks  well. 

Diagnosis. — Syphilitic  inflammation  of  cochlea. 

Was  seen  by  Dr.  Sturgis  in  consultation,  who  found  "an  undoubted  history 
of  syphilis,"  with  objective  evidences  of  the  disease  still  apparent. 


638  SYPHILITIC   COCHLITIS — CASES. 

Patient  was  ordered  to  take  a  mercurial  vapor-bath  daily ;  daily  mercurial 
inunction ;  iodide  of  potash,  beginning  with  60  grains  a  day,  and  gradually  in- 
creasing. 

April  6th.— E.,  -&;  L.,  &;  voice,  2  feet. 

April  13th.— E.,  A ;  L.,  A ;  voice,  2  feet  E.  E. ;  6"  L.  E. 

April  21st.— E.,  -A- ;  L.,  -& ;  voice,  4*  feet  E.  E. ;  1*  feet  L.  E.  Taking  339 
grains  iodide  potash  daily,  with  mercurial  inunction  each  night. 

May  25th. — E.,  -4*8- ;  L.,  &;  voice,  E.,  8  feet;  L.,  4  feet.  Taking  118  grains 
iodide  of  potash  with  20  drops  tincture  iodine,  three  times  daily.  Inunction  as 
usual. 

June  4th. — E.,  ^  ;  L.,  ^ ;  voice,  E.,  4  feet;  L.,  3  feet.  With  face  toward 
speaker,  hears  loud  conversation  10  feet.  Has  always  shown  great  difference 
in  hearing  power  for  different  letters.  Hears  now  w  and  c  best. 

June  25th.— E.,  -^  ;  L.,  ^  ;  voice,  6  feet  right  side ;  4  feet  left  side.  With 
back  to  speaker,  hears  loud  conversation  at  2  feet.  Some  sentences  at  12  feet 
und  more.  Facing  speaker,  hears  ordinary  conversation  easily  at  4  feet,  and 
some  sentences  at  20  feet.  Has  great  difficulty  with  sounds  of  m,  n,  b.  and  p. 
Says  he  heard  the  crickets  in  the  grass  at  the  sea-shore  but  not  the  sound  of 
the  waves  yesterday.  Noises  of  street  disturb  him. 

June  29th. — Left  the  city,  with  orders  to  continue  treatment. 

July  20th. — Writes  that  he  has  gained  six  pounds  since  June  29th. 

August  12th. — Writes  that  he  "hears  everything  quite  naturally,  except 
music."  Sound  of  running  water  in  ears  continues.  Gaining  flesh  and  feeling 
remarkably  well.  Thinks  his  hearing  is  still  improving  a  little. 

The  record  of  this  case  ends  here  for  the  present.  The  patient's  highest 
daily  dose  of  potash  was  369  grains.  The  remedies  agreed  well  with  him,  aiid 
only  had  to  be  interrupted  a  few  times,  for  two  or  three  days,  on  account  of 
causing  disturbance  of  the  stomach.  Inflation  of  the  middle  ears  never  pro- 
duced any  apparent  effect. 

CASE  VI.— Syphilis — Sudden  Tinnitus — Recovery. — Mr.  P ,  aged  forty-five. 

July  2,  1877.  In  July,  1876,  noticed  a  ringing  sound  in  his  left  ear  upon  arising 
in  the  morning.  A  few  days  later  noticed  the  same  sound  in  his  right  ear.  The 
tinnitus  has  remained  ever  since,  and  has  increased  in  intensity.  In  October  he 
noticed  that  his  hearing  was  impaired.  The  deafness  has  been  increasing  until 
three  weeks  ago,  since  which  time  it  has  appeared  to  remain  the  same.  Has  been 
treated  for  aural  catarrh  by  two  competent  aurists  (by  one  for  a  period  of  six 
weeks),  without  any  benefit.  Has  been  treated  by  electricity  also,  without  bene- 
fit. Never  had  any  internal  medication.  Has  occasional  dizziness.  Health  good 
in  all  other  respects. 

Had  a  chancre  in  July,  1876,  before  tinnitus  was  noticed.  Sore  appeared 
fourteen  days  after  intercourse,  healed  slowly,  and  was  accompanied  by  bala- 
nitis.  Never  has  been  aware  of  any  secondary  affection  of  any  kind. 

H.  D. :  E.,  A ;  L.,  &. 

Loud  voice,  six  feet  at  right  side  of  head  and  twelve  feet  at  left  side.  Tun- 
ing-fork heard  alike  both  sides,  as  nearly  as  he  can  judge.  All  the  notes  of  a 
piano  "  sound  alike "  to  him.  Band  music  sounds  very  discordant.  General 
appearance  of  both  drum-heads  is  healthy.  Pharynx  normal.  Tubes  open.  No 
effect  from  inflation. 

Diagnosis. — Disease  of  cochlea,  both  sides,  of  syphilitic  origin? 


SYPHILITIC   COCHLITIS— CASES.  639 

Advised  a  half -drachm  of  twenty  per  cent,  solution  oleate  mercury  rubbed 
into  skin  daily,  and  iodide  of  potash  in  increasing  doses,  beginning  with  5  grains 
three  times  a  day. 

August  14,  1877. — H.  D.,  •/•$  both  sides;  heard  conversation  thirty  feet  be- 
hind back  easily.  B.  E.,  notes  of  piano  between  sixth  c  and  seventh  e  are  not 
heard.  Four  uppermost  notes  heard  naturally.  L.  E.,  notes  sound  natural  up 
to  sixth  g  ;  from  there  to  seventh  e  they  sound  ' '  all  alike,  and  have  no  music  in 
them  ;  "  above  e  they  are  natural  again.  Hears  band  music  well  now ;  before  it 
was  very  discordant  to  him.  Violin  music  is  still  discordant  to  him.  His  own 
voice  sounds  more  natural  to  him.  Is  sure  himself  that  he  hears  everything 
much  better. 

This  patient  left  town  at  this  time,  expecting  to  return,  but  did  not  do  so. 
The  remedies  disagreed  with  him  sometimes,  and  he  was  unnecessarily  timid 
about  increasing  the  doses.  He  never  took  more  than  42  grains  iodide  potash 
three  times  a  day.  A  statement  frora  this  patient,  in  March,  1878,  says  that  he 
considers  himself  well. 


CASE  VII. — Syphilis — Symptoms  of  Cochlear  Disease— Slight  Improvement. — 

Mr.  C ,  aged  thirty.  Seen  at  Manhattan  Eye  and  Ear  Hospital.  Patient 

was  perfectly  deaf  so  far  as  the  voice  was  concerned.  Could  not  hear  the 
watch  with  which  he  was  tested  at  all.  The  vibrations  of  the  tuning-fork 
were  also  not  heard.  All  communication  with  him  had  to  be  held  in  writ- 
ing. He  could  hear  finger-nails  against  the  left  ear  after  three  weeks,  and  the 
tinkling  of  the  street-car  bells.  In  five  weeks  he  could  hear  tuning-fork  quite 
well  with  the  left  ear.  Later  he  heard  the  watch  -/-$  with  the  same  ear.  All  his 
symptoms  pointed  to  a  disease  of  the  labyrinth,  and  it  was  considered  to  be 
syphilitic.  He  had  contracted  syphilis  a  year  before,  and  had  been  treated 
for  it  from  the  outset ;  still  he  had  had  secondary  symptoms.  Six  months  later 
he  felt  so  well  that  he  gave  up  treatment.  Then  he  was  taken  with  violent 
pains  in  his  head,  and  observed  impairment  of  hearing  and  tinnitus.  In  a  week 
his  hearing  was  "all  gone."  He  resumed  anti-syphilitic  treatment,  but  the 
deafness  and  tinnitus  have  remained. 

This  patient  was  treated  with  mercury  and  potash  in  increasing  doses,  and 
carried  out  all  directions  faithfully  for  a  long  time.  His  general  condition  im- 
proved, but  no  change  was  evident  in  his  hearing  except  that  mentioned  above. 
One  day  he  came,  saying  that  on  the  day  before  he  had  heard  the  word  Mexico. 
On  trial,  he  was  found  to  hear  this  word  every  time  it  was  spoken  into  his  left 
ear.  He  did  not  hear  any  of  the  component  letters  of  the  word  (as  x  or  o)  when 
spoken  into  his  ear,  nor  was  any  other  word  ever  found  which  he  could  hear. 
At  this  time  he  was  taken  with  pulmonary  hemorrhages,  and  specific  treatment 
was  stopped.  He  has  been  in  failing  health  ever  since. 

It  is  undoubtedly  true  that  affections  occur  in  syphilitic  pa- 
tients (from  suppression  of  the  perspiration,  for  example),  which 
would  have  occurred  all  the  same  had  they  not  been  syphilitic  ; 
and  yet  the  exposure  or  imprudence  having  once  caused  the 
attack  of  inflammation,  it  immediately  assumes  the  character 
•of  a  syphilitic  affection  by  reason  of  the  syphilitic  blood,  whose 


640  SYPHILITIC   DISEASE   OF   LABYRINTH. 

increased  flow  to  the  part  and  the  exudation  go  to  constitute  the 
inflammation.  The  complete  failure  of  the  anti-catarrhal  treat- 
ment, although  all  these  patients  showed  some  catarrhal  symp- 
toms, was  another  striking  evidence  of  the  real  nature  of  the 
cases ;  for  we  seldom  meet  with  cases  of  catarrh  that  do  not 
respond  to  some  extent  to  the  use  of  the  catheter,  Politzer's 
method,  and  so  forth,  while  in  acute  or  sub-acute  diseases  of  the 
labyrinth,  this  treatment  often  aggravates  the  symptoms. 


CHAPTER  XXII. 

DISEASES  OF  THE  INTERNAL  EAR— (Concluded). 

The  Effects  of  Quinine. — Cerebro-spinal  Meningitis. — Meningitis. — Disease  of  the 
Spinal  Cord. — Parotitis. — Acute  Inflammation  of  Membranous  Labyrinth  mistaken 
for  Cerebro-spinal  Meningitis. — Hemorrhages  and  Effusions. — Injuries. — Concus- 
sions.— Aneurism  and  Tumors. — Disease  of  Semi-circular  Canals. — Pathology. — 
Treatment. 

THE  EFFECTS  OF  QUININE  UPON  THE  LABYRINTH. 

IN  a  paper  read  by  me  before  the  Society  of  Neurology  and  Elec- 
trology  MI  April,  1874, '  I  classified  four  of  the  cases  of  disease  of 
the  internal  ear  then  reported,  as  perhaps  cases  of  congestion 
and  inflammation  of  the  base  of  the  brain  and  labyrinth,  caused 
by  the  internal  administration  of  quinia.  My  remarks  at  that 
time  led  to  a  discussion,  in  which  Dr.  Jacobi  and  Dr.  Hammond 
participated.  To  attempt  a  settlement  of  some  of  the  questions 
involved,  I  undertook  some  experiments  upon  the  human  sub- 
ject, as  did  Dr.  Hammond  upon  animals.  I  believe  these  were 
the  first  experiments  to  determine  the  effects  of  quinine  upon  the 
ear.  They  have  been  followed  by  others,  and  considerable  clin- 
ical experience  has  been  published,  as  to  effects  of  quinine  upon 
the  eye  as  well  as  the  ear,  so  that  the  views  of  the  profession  are 
now  clearer  than  before  the  subject  was  thus  opened  up. 

I  think  large  doses  of  quinine  may  cause  temporary  affections 
of  the  labyrinth,  which  are  made  known  by  tinnitus  aurium  and 
impairment  of  hearing.  This  congestion  is  not,  however,  con- 
fined to  the  membranous  labyrinth,  but  it  may  also  occur  in  the 
tympanic  cavity  and  in  the  auditory  canal.  It  is  so  well  known 
that  buzzing  in  the  ear  is  caused  by  quinine,  that  many  persons 
who  are  becoming  gradually  deaf  from  chronic  catarrhal  or  pro- 
liferous inflammations  of  the  middle  ear,  and  who,'  as  is  the  case 
with  most  other  persons  in  our  country,  have  taken  some  quinine 
in  their  time,  jump  at  the  conclusion  that  the  quinine  caused  the 
impairment  of  hearing  from  which  they  suffer.  Exact  exam- 
ination often  shows  that  many  such  patients  have  never  taken 

1  American  Journal  of  the  Medical  Sciences,  vol.  Ixviii. ,  p   400. 
41 


642  EFFECTS   OF   QUININE. 

quinine  enough  to  cause,  or  even  to  cure  any  disease.  I  object, 
however,  to  the  use  of  quinine  in  aural  disease,  in  any  considera- 
ble doses  ;  for  I  have  been  convinced  by  experimental  and  thera- 
peutical experience  that  it  has  a  peculiar  power  of  producing 
congestion  of  the  ear.  In  1874 '  I  published  a  case,  which  is  re- 
produced on  page  168,  which  proves  this.  My  experiments  with 
quinine  upon  the  healthy  human  subject  were  begun  upon  Dr. 
William  A.  Hammond  May  7,  1874. 

The  optic  papillae  and  the  membranae  tympanorum  were  the 
parts  examined,  as  well  as  the  ocular  conjunctivse  and  auricles. 
"  The  vision  was  normal,  §-§-.  Refraction,  emmetropic ;  pulse, 
90  ;  ocular  conjunctivse  white,  decidedly  free  from  hyperaemia ; 
palpebrae  congested  at  outer  and  inner  canthus.  There  was  no 
tinnitus  aurium.  Membranae  tympanorum  were  entirely  free 
from  evidence  of  blood-vessels.  (I  will  omit  the  details  of  the 
examination  of  the  optic  papillae,  since  we  are  concerned  only 
with  the  effect  of  quinine  upon  the  auditory  apparatus.)" 

Dr.  Hammond  took  gr.  x.  of  sulphate  of  quinine  at  8.30  P.M. 
At  9  P.M.  the  ocular  conjunctivas  were  congested  at  the  outer 
and  inner  canthus  ;  palpebrae  conjunctivas  were  markedly  con- 
gested over  the  whole  surface.  There  was  no  change  in  appear- 
ance of  the  drum-heads. 

"  10  P.M. — Head  feels  full ;  left  ear  rings ;  auricles  burn  ;  face 
is  decidedly  flushed ;  auricles  are  red,  especially  the  lobe  of  right, 
where  there  is  a  localized  congestion  so  marked  as  to  resemble 
an  ecchymosis.  There  is  now  a  vessel  along  each  malleus.  The 
optic  papillae  are  pinkish  from  apparent  enlargement  of  lateral 
vessels. 

"  10.30  P.M. — Right  drum-head  is  very  much  injected  along  the 
handle  of  the  malleus  and  the  upper  margin  ;  left  is  less  red, 
but  still  shows  vascular  injection.  Both  papillae  are  pink,  left 
more  so  than  right ;  face  flushed,  eyes  suffused,  ocular  conjunc- 
tivas decidedly  congested,  slight  headache,  tinnitus  in  both  ears. 

"11  P.M. — The  redness  of  the  auricles  is  diminishing,  espe- 
cially the  circumscribed  spot  on  the  lobe  of  the  left  one  ;  the  face 
still  flushed  ;  tinnitus  continues  ;  no  headache  ;  subject  feels 
exhilarated  ;  drum-heads  still  injected  along  the  malleus  ;  vision 
normal." 

It  should  be  said  that  Dr.  Hammond,  the  subject  of  these 
experiments,  is  a  very  large  and  well-developed  man.  and  that 
he  smoked  a  mild  cigar  during  the  evening. 

On  May  28,  1875,  I  repeated  the  experiment  upon  Dr.  E. 
T.  E ,  aged  twenty-four,  a  man  of  about  five  feet  six  inches 


1  Transactions  of  the  American  Otological  Society. 


EFFECTS   OF   QUININE.  643 

in  height,  well  developed,  in  good  health  and  vigor.  He  stated 
that  he  never  had  had  otitis.  The  hearing  distance  is  |-|  on 
each  side  ;  refraction  -emmetropic.  He  has  no  tinnitus  aurium. 
The  drum-heads  are  free  from  vessels,  and  normal  in  appear- 
ance ;  optic  papillae  normal.  At  11.05  A.M.  Dr.  E takes  gr.  x. 

of  sulphate  of  quinine.  At  11.35  there  is  a  very  fine  vessel 
along  the  right  malleus  ;  no  change  in  the  left.  At  12.30  there 
is  some  redness  at  the  periphery  of  the  left  drum-head,  but  the 
vessel  on  the  right  has  disappeared.  At  1  P.M.  the  redness  has 
disappeared  from  both  sides.  No  change  is  observed  in  the 
optic  papillae.  There  is  no  tinnitus,  and  no  sense  of  exhilara- 
tion. No  tobacco  or  other  stimulant  was  used  during  the  time 
of  observation. 

June  23,  1875. — Dr.  C ,  aged  twenty-five,  about  five  feet 

nine  inches  in  height,  rather  spare.  Refraction  myopic,  ^  v.  = 
ff.  Drum-heads  absolutely  free  from  congestion.  No  vessel  on 
or  along  malleus.  Optic  papillse  are  both  flushed. 

At  10.16  A.M.  takes  gr.  xv.  of  sulphate  of  quinine.  11  A.M.,  a 
vessel  is  seen  along  malleus  of  right  membrana  tympani ;  and 
left  membrana  tympani  presents  no  change.  There  is  slight 
vertigo.  11.30. — There  is  a  sense  of  heat  and  tingling  over  the 
whole  surface  of  the  body.  Sense  of  fulness  in  ears  and  head. 
The  handles  of  both  mallei  are  injected.  The  hands  are  tremu- 
lous, and  the  subject  gives  general  evidence  of  nervous  excite- 
ment. There  are  sounds  of  a  high  note  in  the  ears.  The  ears 
feel  warm.  At  12.30  the  injection  of  the  malleus  is  disappear- 
ing, as  are  the  vertigo  and  tremor.  At  12.50  the  mallei  are  still 
injected.  Motions  of  the  jaw  cause  peculiar  and  unpleasant 
sense  of  vibration  in  the  ears. 

Although  these  experiments  are  but  three  in  number,  they 
are  sufficient,  I  think,  to  justify  the  view  I  expressed  in  the 
American  Journal  of  the  Medical  Sciences,  October.  1874,  that 
the  effects  of  quinine  upon  the  ear  were  due  to  congestion. 
That  view  was  contested  at  the  time  of  reading  the  paper. '  by 
Professor  Jacobi,  on  the  ground  that  some  observations  that  had 
been  made  in  Germany,  as  well  as  clinical  experience,  seemed 
to  show  that  anaemia,  and  not  congestion,  was  one  of  the  effects 
of  the  use  of  quinine  ;  that  is  to  say,  it  was  claimed  that  con- 
traction and  not  dilatation  of  the  vessels  was  produced  by  the 
drug.  Dr.  Hammond's  experiments  upon  animals,  and.  what  is 
much  more  conclusive  than  even  experiments  upon  animals, 
large  clinical  experience,  some  of  which  is  given  us  by  such 
observers  as  the  late  Von  Graefe.2  confirm  the  view  deduced 


1  New  York  Society  of  Neurology  and  Electrology. 
8  Archiv  fur  Ophthalmologie,  Bd.  III.  2,  p.  396. 


644  EFFECTS    OF   QUININE. 

from  my  observations,  that  the  tinnitus  aurium  following  the 
use  of  quinine  is  the  result  of  overfilled  blood-vessels,  and  is  not 
the  anaemia  of  blood-vessels  not  containing  the  normal  quality 
or  quantity  of  fluid. 

It  should  also  be  stated,  that  I  have  experimented  upon  two 
other  physicians,  giving  each  ten  grains  of  quinine  at  a  dose. 
I  have  no  notes  of  these  cases,  but  I  may  say  that  in  one  case 
congestion  of  the  drum-heads  and  of  the  optic  papillae  followed, 
with  tinnitus  aurium,  while  in  the  other  absolutely  no  effect  was 
produced.  The  former  subject  was  a  full-blooded  man  who  had 
suffered  from  congestion  of  the  cerebral  meninges.  The  gentle- 
man upon  whom  no  effect  was  produced  had  been  in  the  habit 
of  taking  quinine,  and  was  rather  anaemic. 

Dr.  Hammond '  published  some  experiments  on  this  subject 
in  a  paper  in  which  he  gives  the  literature  of  the  subject,  and 
particularly  the  experience  of  M.  Melier  (Experiences  et  Ob- 
servations sur  les  Proprietes  Toxiques  du  Sulfate  de  Quinine. 
Memoires  de  VAcademie  Royale  de  Medecine,  etc.,  p.  722).  Melier 
is  very  decided  as  to  quinine  causing  deafness,  as  are  other 
writers  ;  but  observations  as  to  the  immediate  effect  of  the  drug 
upon  the  membrana  tympani  or  other  parts  of  the  ear  do  not  ap- 
pear, except  in  the  account  of  Dr.  Hammond's  own  case. 

The  observations  that  have  been  made  upon  the  f  undus  oculi, 
after  the  administration  of  large  doses  of  quinine,  indicate  that 
the  secondary  effect  of  toxic,  or  large  doses  of  this  drug,  is  to 
empty  the  blood-vessels.  It  has  been  assumed,  I  think,  that  is- 
chaemia  of  the  retina  is  the  first  consequence  of  a  poisonous  or 
large  dose.  But  the  fundus  oculi  has  not  yet  been  examined  in 
such  cases,  as  soon  as  the  loss  of  vision  occurred. 

The  following  case  reported  by  me,"  awakened  such  attention 
to  the  effects  of  quinine  upon  the  eye  as  well  as  ear,  that  the 
experiments  upon  animals  were  continued,  and  clinical  reports 
were  furnished  from  various  sources.  They  have,  as  it  seems 
to  me,  nearly  all  served  to  confirm  the  views,  that  I  was  the  first 
to  clearly  express,  as  to  the  possible  danger  fr.om  the  use  of  this 
drug,  and  the  opinion  that  congestion  is  the  primary  effect  of  a 
large  dose. 

A  Case  of  Poisoning  from  the  use  of  the  Compound  Tincture  of  CincJiona,  producing 
Permanent  Contraction  of  the  Visual  Fields  and  Temporary  Impairment  of  Sight 
and  Hearing. 

On  July  3,  1878,  Dr.  L.  M.  Yale  asked  rne  to  see  a  case  of  loss  of  sight,  of 
which  the  following  history  was  obtained  :  Mr.  B ,  aged  fifty,  a  man  of  very 

1  Psychological  and  Medico-Legal  Journal,  October,  1874,  p.  232. 
*  Archives  of  Ophthalmology,  vol.  viii. ,  p.  392. 


EFFECTS   OF   QUININE.  645 

intemperate  habits  as  regards  the  use  of  alcohol.  He  had  been  accustomed  for 
years  to  drink  enormously  of  brandy  and  whiskey  at  intervals,  but  there  were 
periods  of  varying  length,  from  one  to  three  or  four  months,  of  total  abstinence 
from  intoxicating  drinks. 

Mr.  B was  told  that  the  use  of  the  tincture  of  cinchona  would  relieve 

him  from  his  periodic  craving  for  alcohol.  On  June  24th  of  that  year  he  began 
its  use,  with  a  view  of  correcting  his  intemperate  habits.  On  that  day,  as 
well  as  on  the  25th,  26th,  27th,  and  28th,  he  continued  to  take  the  compound 
tincture  in  ounce  and  two-ounce  doses,  at  short  intervals,  literally  drinking  it  as 
a  beverage  from  a  quart  bottle,  in  which  he  had  caused  an  apothecary  to  place  as 
strong  a  preparation  as  possible.  On  the  28th,  although  he  had  taken  none  of 
his  ordinary  alcoholic  stimulants,  his  clerk  thought  from  his  conduct  that  Mr. 

B had  been  drinking  heavily.  Dr.  Yale  estimated  that  in  these  days  the 

patient  took  an  amount  of  the  tincture  which  would  be  equivalent  to  125  '  grains 

of  an  alkaloid  of  cinchona.  Mr.  B has  no  recollection  of  any  occurrence 

after  the  27th.  He  is  confident  that  he  took  no  alcohol,  except  that  contained 
in  the  preparation  of  cinchona,  during  these  days.  This,  however,  may  be 
doubtful,  for  the  clerk  of  the  hotel  to  which  he  went  when  in  what  proved  to 
be  a  semi-conscious  state  on  the  28th,  states  that  while  he  lay  in  bed  he  was 
constantly  ringing  the  bell  for  liquor.  It  is  possible  that  during  this  time  some 

doses  of  alcohol  were  added  to  those  of  cinchona,  although  Mr.  B does  not 

believe  this  to  be  the  case.  On  the  morning  of  July  1st  he  was  seen  by  Dr. 
Hills  in  the  absence  of  Dr.  Yale.  He  found  the  patient  stupid  or  half -conscious, 
with  flushed  face  and  conjunctivse,  and  apparently  unable  to  see  or  hear.  Mr. 

B remembers  Dr.  Hills'  visit  on  Sunday,  and  knows  that  he  was  then  blind 

and  deaf.  Dr.  Yale  saw  the  patient  on  Monday  and  Tuesday,  July  2d  and  3d. 
His  hearing  power  improved  so  much  in  that  time  as  to  become  apparently  nor- 
mal, but  his  vision  remained  very  much  impaired.  On  the  day  I  saw  Mr.  B , 

the  3d,  he  was  groping  about  his  room,  apparently  in  excellent  general  health  and 
with  good  hearing.  V.,  K.  E.  =  quantitative  perception  of  light.  L.  E.  counts 
fingers  at  one  foot.  The  ophthalmoscope  showed  lessened  size  of  the  arterial 
vessels  ;  no  abnormity  in  the  veins,  lessened  number  of  vessels  on  the  papills?, 
but  no  marked  paleness.  No  changes  observed  in  tlie  membrana  tympani.  The 
patient  was  advised  to  take  strychnia  in  increasing  doses  and  nutritious  diet. 
On  July  6th  he  was  able  to  walk  about.  V.  =  f  S  each  eye,  but  the  visual  fields 
were  very  much  contracted,  so  that  vision  was  telescopic. 

On  July  16,  1878,  both  visual  fields  were  found  concentrically  limited.  The 
measurements,  drawn  on  a  blackboard  14"  distant,  were  as  follows  :  Eight  field, 
vertical,  9  inches ;  horizontal,  7£  inches  ;  limitation  most  marked  on  temporal 
side.  Left  field,  vertical,  7  inches ;  horizontal,  8  inches ;  limitation  more 

regular.  B found  this  symptom  rather  novel  than  troublesome.  The  optic 

papillae  looked  very  pale,  and  the  arteries  were  narrow.  July  23d,  V.  =  if],  each 
eye.  Patient  states  that  he  can  see  perfectly  well  in  a  straight  line,  but  that 
when  walking  about  a  room  he  has  some  difficulty  in  seeing  small  articles  of 
furniture. 

September  10th. — The  same  condition  is  maintained.  The  strychnia  was 
taken  until  -fa  grain  had  been  reached  at  a  dose,  and  was  continued  for  two 
months.  The  visual  field  remains  as  on  July  16th. 

1  This  amouHt  was  afterward  found  to  be  nearer  50?  grains. 


646  EFFECTS   OF   QUININE. 

April  23,  1879. — Mr.  B 's  condition  remains  substantially  the  same.     He 

continues  to  abstain  entirely  from  the  use  of  alcohol,  and  carries  on  a  large  busi- 
ness successfully.  His  vision  is  still  ftf  each  eye.  The  visual  field  has  increased 
somewhat  in  the  left  eye.  It  now  measures  9  inches  vertically  and  16  inches 
horizontally.  F.  of  B.  E.  6"  vertically,  9"  horizontally.  Limitation  most 
marked  at  upper-inner  quadrant.  The  optic  disks  are  pale  and  the  arteries  small. 
There  are  no  other  ophthaimoscopic  appearances. 

Mr.  B- had  taken  no  alcohol  for  some  months  prior  to  his 

beginning  the  use  of  the  cinchona,  and  he  took  none  until  he  be- 
came unconscious  on  the  fourth  or  fifth  day.  Although  he  went 
about  and  transacted  business  on  the  fourth  day,  he  has  no  rec- 
ollection of  what  he  did.  When  found  he  had  an  empty  bottle 
(holding  a  quart)  in  his  room,  labelled  and  giving  positive  evi- 
dence of  having  contained  cinchona.  He  certainly  did  not  take 
many  drinks,  if  any,  after  he  reached  the  hotel,  for  the  clerk, 
knowing  his  former  habits,  and  supposing  him  to  be  suffering 
from  an  ordinary  debauch,  refused  to  answer  his  demands.  It 
is  not  known  that  he  took  anything  but  the  cinchona  at  any  time 
after  he  began  the  treatment  of  the  alcohol  habit. 

We  have  here,  then,  a  case  of  hypersemia  of  the  vessels  of 
the  ear  from  the  use  of  cinchona  and  alcohol — a  hypersemia 
which  passed  away  without  going  on  to  an  exudative  process  ; 
but  the  same  condition  in  the  vessels  supplying  the  retina  con- 
tinued until  a  true  vasculitis,  with  its  consequences,  resulted. 

The  following  case  was  considered  to  be  one  of  chronic  catarrh 
of  the  middle  ears,  with  affection  of  the  cochlea.  While  under 
treatment  it  happened  to  furnish  an  illustration  of  the  effects  of 
quinine  upon  the  ears  : 

Injury  of  the  Cochlea  from  Cannonading — Effects  of  Quinine  on  the  Ear. — Dr. 

P ,  aged  fifty-one.  In  1870  was  exposed  to  heavy  cannonading,  after  which 

he  had  sudden  tinnitus  and  impairment  of  hearing  on  both  sides.  The  symp- 
toms passed  away  in  great  measure  within  a  short  time.  Since  then  he  has  had 
the  tinnitus  only  occasionally.  The  deafness  has  not  been  enough  to  annoy  him 
until  lately.  Thinks  the  right  ear  has  always  been  the  worse.  A  year  and  a  half 
ago  he  noticed  that  he  heard  the  click  preceding  the  striking  of  his  clock,  but 
did  not  hear  the  strike.  Now  he  hears  the  strike,  but  not  the  click.  Hears 
worse  in  a  noisy  place.  Has  been  troubled  with  irritation  and  excess  of  secretion 
in  pharynx  for  a  long  time.  Health  otherwise  excellent. 

H.  D.— B.  E.,  -&;  L.  E.,  ^.     Voice,  fifty  feet  behind  back. 

Tuning-fork  placed  on  teeth  is  heard  alike.  Plugging  either  ear  makes  no 
difference.  Placed  on  forehead  or  vertex  is  heard  alike,  but  better  on  left  side 
when  plugged.  Placed  on  mastoid  heard  better  on  left  side  than  on  right ; 
plugging  left  ear  intensifies  sound  of  fork;  plugging  the  right  ear  makes  no 
difference.  All  the  notes  of  the  piano  are  heard  well  with  the  left  ear.  The 
right  ear  has  partially  lost  its  perception  of  some  of  the  lower  and  some  of  the 
upper  notes,  but  hears  the  others  well. 


EFFECTS   OF   QUININE.  647 

Eight  drum-head  :  Opaque.     Light  spot,  narrow  and  divided. 

Left  dram-head  :  Opaque.     Good  light  spot. 

Pharynx  catarrhal. 

Inflation  for  three  weeks  improved  the  hearing  for  the  watch  to  &  on  both 
sides. 

One  morning,  while  under  treatment,  the  patient  came  complaining  of  great 
"stuffiness"  and  tinnitus  in  both  ears.  During  the  preceding  twenty -four  hours 
he  had  taken  thirty-eight  grains  of  quinine  for  neuralgia.  The  hearing  for  the 
watch  was  ^.r  R.  E.,  and  A  L.  E.  There  was  intense  redness  along  each  malleus- 
handle.  (The  day  before  the  hearing  had  been  -4stf  each  side,  and  no  redness  of 
the  drum-heads  existed  on  that  day,  or  had  ever  been  seen  before.)  Inflation  did 
not  improve  the  hearing  at  all,  although  it  had  never  failed  to  do  so  before. 
At  the  next  visit  the  conditions  were  as  usual. 

Several  weeks  after  stopping  treatment,  the  hearing  had  relapsed  to  its 
former  state. 

In  an  inaugural  dissertation  Dr.  Hans  Brunner '  has  collected 
the  cases  of  amblyopia  caused  by  quinine,  and  also  gives  the  re- 
sult of  experiments  made  with  the  drug.  Until  the  observations 
of  Briquet,  Paris,  1855,  who  saw  four  cases  of  temporary  blind- 
ness found  in  four  persons  from  daily  doses  of  from  3  to  5.0 
grammes,  they  are  not  of  any  importance.  Briquet  thinks  that 
impairment  of  vision  occurs  less  frequently  than  impairment  of 
hearing.  Dr.  Virsinier,  of  Louisiana,  quoted  by  Brunner,  has 
seen  deafness  occur  without  blindness,  but  never  blindness  un- 
accompanied by  deafness.  One  of  his  patients,  during  an  attack 
of  intermittent  fever  of  a  pernicious  variety,  took  4.0  grammes 
of  sulphate  of  quinine  within  six  hours,  and  just  as  much  during 
the  same  time  in  an  enema.  On  the  next  day  the  patient  was 
deaf  and  blind. 

Dr.  Baldwin,  of  Alabama,  has  warned  the  profession  on  sev- 
eral occasions  of  the  dangers  to  sight,  hearing,  and  even  life, 
from  large  doses. 

Weber- Liel,"  quoted  by  Brunner,  verifies  my  views  as  to  con- 
gestion of  the  ears  being  caused  by  quinine.  Kirchner.3  in  an 
article  upon  the  effects  of  sulphate  of  quinine  upon  the  tempera- 
ture and  circulation,  states  as  the  result  of  his  experiments,  that 
quinine  causes  inflammatory  processes  and  permanent  patholog- 
ical changes  in  the  ear.  He  believes  that  the  cause  for  these  con- 
ditions is  to  be  found  not  only  in  a  hypercemia  of  short  duration, 
but  also  in  paralysis  of  the  vessels  with  congestion  and  exuda- 
tion. 

I  believe  that  the  tinnitus  aurium  and  impairment  of  hear- 


1  Ueber  Chininamaurose.     Dissenhoffen,  1882.  5  Loc.  cit.,  p.  36. 

3  Berlin.  Klin.  Wochenschrift,  1881,  p.  725. 


648  EFFECTS   OF   QUININE. 

ing,  following  the  use  of  quinine,  depend  upon  congestion  of  the 
ultimate  fibres  of  the  auditory  nerve  in  the  cochlea,  and  that  the 
redness  of  the  drum-heads  is  merely  an  index  of  the  former  con- 
dition. 

Since  the  publication  of  the  last  edition  I  have  had  the  oppor- 
tunity of  carefully  examining  a  patient  with  typhoid  fever,  who 
was  profoundly  under  the  influence  of  quinine,  so  that  she  could 
not  hear  ordinary  conversation,  a  person  with  good  hearing  be- 
fore the  administration  of  the  quinine,  and  who  perfectly  recov- 
ered her  hearing  power  after  the  effects  of  the  quinine  had 
passed  away.  The  patient  heard  the  tuning-fork  better  through 
the  air  than  the  bone,  indeed,  the  bone-conduction-was  nearly 
destroyed.  This  completes  the  chain  of  proof  that  the  lesion  in 
deafness  from  quinine  is  in  the  internal  ear. 

In  the  treatment  of  deafness  from  quinine  I  have  used  strych- 
nia with  great  benefit.  Mercury  and  potash  should  not  be 
given,  nor  should  depletives  be  used  in  any  form. 

Since  the  publication  of  the  last  edition  of  this  work,  I  have 
seen  a  very  interesting  case  of  deafness  following  the  use  of 
quinine,  which  I  reported  in  full  elsewhere.1  It  was  that  of  an 
officer  of  the  navy,  about  forty-nine  years  of  age,  who,  having 
excellent  hearing,  took  twenty  grains  of  sulphate  of  quinine  one 
evening  after  a  wetting  from  exposure  to  a  storm,  and  woke  up 
profoundly  deaf.  He  never  had  had  syphilis.  The  use  of  leeches 
and  the  internal  administration  of  mercury  was  begun  the  day 
the  deafness  occurred,  but  the  patient  continued  profoundly  deaf, 
with  very  unpleasant  head  symptoms,  until  strychnia  and  alco- 
holic stimulants  were  used,  when  he  immediately  began  to  im- 
prove. He  ultimately  recovered  the  hearing  of  one  ear  in  good 
proportion,  but  the  other  remains  profoundly  deaf. 

Fortunately  most  of  the  cases  of  deafness  caused  by  quinine 
fully  recover.  In  some,  however,  most  deplorable  results  occur. 
It  is  a  drug  that  should  never  be  lightly  administered  to  any 
person,  and  especially  to  any  one  already  affected  with  aural 
disease,  unless  in  the  rare  cases  of  malarial  neuralgia  of  the 
middle  ear. 

Kirchner  found  diminution  in  the  perception  of  a  vibratory 
tuning-fork  placed  upon  the  bones  of  the  head,  and  also  a  dimin- 
ished perception  of  the  higher  tones.  Orne  Green,"  on  reviewing 
the  literature  of  this  subject  and  giving  his  own  large  clinical 
experience,  quotes  my  views  and  their  corroboration  by  Kirchner 
with  approbation,  and  states  :  From  our  present  knowledge,  both 
clinical  and  experimental,  we  are  justified  in  asserting  that  the 
action  of  quinine  upon  the  ears  is  to  produce  congestion  of  the 

1  International  Congress  of  Otology,  Brussels.  1882. 

J  Boston  Medical  and  Surgical  Journal,  vol.  cviii..  p   220. 


CEREBRO-SPINAL    MENINGITIS.  649 

labyrinth  and  tympanum,  and  sometimes  distinct  inflammation, 
with  permanent  tissue  changes. 

DISEASE  OP  THE  ACOUSTIC  NERVES  CAUSED  BY  CEREBRO-SPINAL 

MENINGITIS. 

Cerebrospinal  meningitis  has  been  generally  supposed  to  be 
the  cause  of  many  cases  of  disease  of  the  auditory  nerves.  That 
it  frequently  causes  great  loss  of  hearing,  and  sometimes  abso- 
lute deafness,  no  one  with  the  least  clinical  experience  will  deny. 
A  large  proportion  of  the  deaf-mutes  of  the  present  day  are  said 
to  have  lost  their  hearing  in  the  course  of  cerebro-spinal  menin- 
gitis. I  believe,  however,  that  although  the  trunk  of  the  acoustic 
nerve  and  the  labyrinth  may  become  diseased,  and  perhaps  pri- 
marily in  some  cases,  that  the  lesion  of  the  ear  that  most  fre- 
quently occurs  in  the  disease  is  an  inflammation  in  the  tympa- 
num. Judging  from  the  analogous  process  that  occurs  in  the 
eye,  this  seems  a  plausible  view.  We  do  not  usually  have  optic 
neuritis  when  the  eye  becomes  affected  in  cerebro-spinal  men- 
ingitis, but  choroiditis — a  peripheric  and  not  a  central  affection. 
The  pathological  investigations  in  this  direction  have  been  few, 
apparently  because  general  pathologists  are  not  much  inter- 
ested in  the  ear,  and  those  who  concern  themselves  with  its  dis- 
eases have  few  opportunities  to  make  post-mortem  examinations 
in  cases  of  cerebro-spinal  meningitis.  The  clinical  facts  are 
against  the  theory  of  disease  of  the  nerves.  There  is  scarcely 
ever  facial  paralysis  in  conjunction  with  the  deafness.  It  is 
hard  to  conceive  of  suppuration  of  the  trunk  of  the  acoustic 
nerve,  without  any  affection  of  the  facial,  and  although  this  ab- 
sence of  facial  paralysis  does  not  prove  Voltolini's  view,  nearly 
all  the  cases  of  loss  of  hearing  said  to  result  from  cerebro-spinal 
meningitis,  actually  depend  upon  inflammation  of  the  membra- 
nous labyrinth.  It  assists  us  to  believe  that  the  first  lesion  may 
often  be  in  the  tympanum.  The  evidence  furnished  by  the  drum- 
heads, which  are  so  often  sunken,  although  not  conclusive — for 
we  may  have  secondary  disease  of  the  tympanum  as  well  as  of 
the  labyrinth — is  another  point  in  the  clinical  evidence.  Then 
the  tuning-fork,  in  many  cases,  notably  in  deaf-mutes,  is  heard 
through  the  bones,  when  it  is  not  at  all  perceived  through  the 
air.  Disease  of  the  acoustic  nerve  has,  however,  been  found 
in  post-mortem  examinations  of  cases  of  this  disease.  Wie- 
meyer,  quoted  by  Moos,1  remarks  that  he  does  not  consider  it 
improbable  that  "the  deafness  and  impairment  of  hearing  may 
be  produced  by  different  causes,"  but  he  states  that  Luschkaand 
himself  found  the  acoustic  nerve,  up  to  its  exit  from  the  skull, 
so  completely  embedded  in  masses  of  exudation,  that  Professor 

1  Archives  of  Ophthalmology  and  Otology,  vol.  ii. ,  p.  G22. 


650  CEREBRO-SPINAL   MENINGITIS. 

Luschka  felt  justified  in  supposing  that  the  inflammation  and 
exudation  following  the  course  of  the  nerves  might  easily,  in 
some  cases,  extend  into  the  labyrinth.  Moos,  in  this  same 
paper,  gives  a  report  of  the  necroscopy  of  two  cases  in  which 
there  was  found  pus  in  each  tympanum,  also  in  the  vestibules, 
and  ampullae,  and  the  cochlea.  Both  the  acoustic  and  facial 
nerves  in  the  meatus  auditorius  were  surrounded  by  pus.  The 
second  case  presented  similar  appearances. 

It  has  been  pretty  generally  assumed  that  these  cases  were 
cases  in  which  the  trunk  of  the  acoustic  nerve  was  primarily 
affected,  but  it  is  by  no  means  certain  that  the  primary  trouble 
here  alsjo  was  not  in  the  tympanum  whence  it  may  have  ex- 
tended to  the  labyrinth  and  nerve. 

The  cases  reported  by  Heller  '  show  that  he  considers  it  pos- 
sible, from  his  microscopic  examinations,  that  the  suppuration 
in  the  tympana  and  labyrinth  may  have  occurred  simultane- 
ously with  the  changes  in  the  cerebral  and  spinal  membranes. 
Lucse  *  reports  a  case  which  more  fully  supports  the  view  of  a 
primary  affection  of  the  labyrinth  in  cerebro-spinal  meningitis 
than  do  any  of  the  preceding  cases.  In  his  case  there  was 
merely  congestion  of  the  tympana,  while  the  Eustachian  tubes 
were  in  a  normal  condition  and  the  labyrinths  were  in  a  state 
of  suppuration.  "  The  purulent  inflammation  of  the  base  of  the 
brain  along  the  vessels  of  the  acoustic  nerve,  up  to  the  cochlea, . 
was  more  exactly  traced  on  both  sides."  Knapp s  found  "symp- 
toms of  hypersemia  or  catarrhal  inflammation  of  the  middle  ear, 
either  during  the  febrile  stage  of  the  disease  or  during  the  period 
of  convalescence"  in  many  cases.  Knapp  also  examined  two 
temporal  bones  of  a  patient  who  had  become  deaf  and  died  from 
cerebro-spinal  meningitis.  In  one  ear  the  outer  and  middle  ears 
were  normal,  while  the  acoustic  nerve  was  softened  by  suppura- 
tion. While  the  accompanying  facial  appeared  to  be  normal,  the 
acoustic  nerve  of  the  other  side  had  not  suffered,  but  numerous 
pus-cells  were  found  around  it.  The  labyrinth  was  not  examined. 

Moos,4  however,  reports  the  post  mortem  of  a  case  of  cerebro- 
spinal  meningitis,  in  which  the  nerve  was  found  to  be  sound, 
excepting  some  congestion  of  the  sheath  up  to  the  meatus  audi- 
torius internus,  while  there  was  extension  of  the  inflammation 
from  the  dura  mater  into  both  tympanic  cavities. 

Von  Troltsch  says  that  a  few  post-mortem  examinations 
show  that  the  morbid  changes  causing  deafness  in  cerebro- 
spinal  meningitis  are  sometimes  found  in  the  fourth  ventricle. 

1  Archiv  fur  Ohrenheilknnde,  Bd.  IV.,  p.  55. 
•*  Ibid.,  Bd.  V.,  p.  188. 

3  Transactions  of  the  American  Otological  Society,  1873. 

4  Archives  of  Ophthalmology  and  Otology,  vol.  iii.,  No.  2,  p.  177. 


CEKEBRO-SPINAL    MENINGITIS.  651 

Professor  J.  Lewis  Smith1  says  that  "inflammation  of  the 
middle  ear,  of  a  mild  grade  and  subsiding  without  impairment 
of  hearing,  is  common."  Dr.  Smith  also  says  that  suppuration 
of  the  tympanum  may  occur.  According  to  his  statistics,  about 
one  in  every  ten  patients  becomes  deaf. 

I  have  seen  congestion  of  the  tympanum  in  recent  cases  of 
the  disease  under  discussion,  and  I  have  seen  many  where  the 
labyrinth  was  the  seat  of  disease,  but  whether  primarily  or  sec- 
ondarily so,  I  cannot  say.  It  is  probable  that  the  inflammatory 
process  sometimes,  and,  as  I  think,  generally,  follows  the  blood- 
vessels into  the  tympanum  rather  than  along  the  acoustic  nerve, 
for  in  most  of  the  cases  I  have  seen  there  is  still  some  hearing 
power  by  bone-conduction,  to  me  a  positive  indication  that  some; 
power  remains  in  the  acoustic  nerve.  .  „ 

The  following  cases  illustrate  the  clinical  appearances  : 

CASE  I.  —  Cerebro- Spinal  Meningitis — Bilateral  Deafness — Both   Drum-Heads 

Sunken. — December  30,  1869.     E.  M.  W ,  aged  thirteen,  five  years  ago  this 

winter  had  an  inflammatory  disease  of  the  head  and  joints,  and  when  he  recovered 
from  this  affection  became  deaf.  He  does  not  hear  words  in  any  way.  He  feels 
the  tuning-fork  placed  on  the  bones  in  each  ear.  The  membranse  tympani  of  both 
sides  are  sunken  ;  the  pharynx  and  nares  are  in  a  healthy  condition  ;  air  enters 
both  tympanic  cavities. 

CASE  II.  —  Cerebro-Spinal  Meningitis — Absolute  Deafness— Both   Drum-Heads 

Sunken. — C.  M ,  boy,  aged  four  years  and  eight  months,  heard  and  talked 

well  until  about  a  year  ago,  when  he  had  a  fit  of  sickness,  which  the  parents  de- 
scribed very  imperfectly,  but  which  was  attended  by  some  loss  of  power  in  the 
limbs.  There  was  at  one  time  some  discharge  of  pus  from  one  of  the  ears.  The 
child  does  not  seem  to  hear  sounds  at  all ;  the  vibrations  of  a  large  tuning-fork 
are  not  perceived.  Both  drum-heads  sunken  and  pinkish. 

CASE  III. — Cerebro-Spinal  Meningitis — Deafness  Absolute — Membrane  Tympani 

Nwmal . — May  22,  1872.     D.  W.  K ,  aged  twenty-one,  a  little  more  than  three 

months  since  was  attacked  by  some  disease  of  the  head,  and  for  two  weeks  was 
stupid  or  delirious.  There  were  some  little  spots  on  the  neck.  When  he  be- 
came conscious,  he  could  not  hear ;  he  has  remained  deaf  ever  since.  There 
seems  to  be  absolutely  no  hearing  power  ;  cannot  hear  the  voice  even  when  con- 
veyed to  the  ear  through  a  tube  ;  and  is  equally  unconscious  of  the  sound  of  the 
tuning-fork  or  the  piano.  The  membranse  tympani  are  of  normal  color,  trans- 
parency, and  position  ;  air  enters  the  tympanic  cavities. 

CASE  IV. — Cerebro-Spinal  Meningitis — Sunken  Drum-Heads. —George  S , 

aged  twenty-five  months,  when  fourteen  months  old  had  congestion  of  the  brain  ; 
was  unconscious,  paralyzed,  and  had  spots  on  the  skin.  Was  found  to  be  deaf 
when  he  recovered.  Both  membranae  tympani  are  sunken. 

CASE  V. — Cerebro-Spinal  Meningitis— Sunken   Drum-Heads.— May  31,  1873. 

John  D ,  aged  nine,  eight  weeks  ago  to-day  was  seized  with  a  pain  in  his  head 

at  about  8  o'clock  A.M.  The  pain  was  said  to  be  across  the  forehead.  At  11 
o'clock  he  had  convulsions.  There  was  spasm,  especially  of  the  hands  and 


1  Medical  Record.  December  8,  1883. 


652  MENINGITIS. 

throat,  at  8  P.M.  ;  complained  of  headache,  and  at  11  P.M.  he  vomited.  He  be- 
came unconscious,  and  remained  so  until  4  A.M.  Ten  days  after  the  attacks  he 
was  deaf,  and  still  continues  to  be  so.  He  states  that  there  is  a  whistling  sound 
in  his  ears.  He  took  large  doses  of  quinia,  and  soon  recovered  from  all  the  symp- 
toms, except  a  little  uncertainty  in  his  steps,  and  even  now  he  has  a  somewhat 
tottering  gait.  He  does  not  hear  the  watch  at  all ;  but  can  distinguish  sounds 
conducted  into  his  ear  through  a  tube.  The  tuning-fork,  when  placed  upon  the 
teeth,  produces  a  buzzing  noise.  The  drum  membranes  are  very  much  sunken, 
and  of  a  pinkish  hue  ;  show  a  small  light  spot. 

CASE  VI.  -  -  Cerebro-Spinal  Meningitis — Normal   Membranes    Tympani — Slight 

Amount  of  Hearing  Power  as  Tested  by  Piano. — March  17,  1874.     D.  B ,  aged 

twenty-one,  a  little  more  than  ten  months  ago  was  attacked  with  a  chill,  which 
was  attributed  to  sitting  upon  a  stone  in  the  front  of  the  house  during  the  month 
of  May.  After  the  chill  the  patient  became  delirious,  and  his  neck  was  stiff,  and 
he  had  no  use  of  his  arms  or  legs.  This  state  of  things  continued  for  one  week. 
As  soon  as  he  became  rational  he  was  found  to  be  deaf,  and  his  left  side  re- 
mained paralyzed.  He  gradually  recovered  from  the  paralysis,  though  his  deaf- 
ness continues,  and  he  staggers  in  his  walk.  Hearing  distance  :  right,  0  ;  left,  0. 
The  tuning-fork  is  faintly  heard  in  both  ears  ;  he  is  sensible  of  the  tones  of  his 
own  voice,  and  talks  in  a  natural  tone,  modulating  fairly.  He  thinks  his  right 
ear  is  the  better  One.  By  means  of  a  conversation  tube  connected  with  the 
keys  of  a  piano,  he  is  enabled,  through  the  medium  of  the  right  ear,  to  distin- 
guish the  C,  D,  and  E  of  the  treble,  as  well  as  all  the  bass  notes.  With  the 
left  ear  he  cannot  distinguish  the  treble,  the  bass  notes  alone  being  audible. 
This  is  in  accordance  with  the  law  of  acoustics,  that  the  impression  of  the  bass 
or  low  notes  remains  longer  on  the  ear,  thus  proving  that  the  patient  had  still 
a  slight  trace  of  hearing  power  remaining  in  the  cochlea,  and  that  the  state- 
ment that  he  heard  better  with  the  right  ear  was  correct.  The  membranae 
tympani  are  transparent,  the  pharynx  is  granular.  The  patient  has  been  for 
some  weeks  under  competent  treatment,  but  without  perceptible  benefit. 

CASE  VII. — Cerebro-Spinal  Meningitis — Normal  Membrane  Tympani. — May  2, 

1872.     Virgil  T ,  aged  five,  four  weeks  ago  was  seized  with  a  severe  pain  in 

the  head  ;  soon  vomited,  and  was  delirious  at  times,  especially  on  waking  from 
sleep.  He  complains  of  pain  in  the  back  and  neck,  and  also  of  pain  in  his  right 
ear.  Four  days  after  the  attack  began  he  was  found  to  be  deaf,  which  symp- 
tom increased  after  a  second  attack  of  pain.  Apparently  there  is  an  entire  ab- 
sence of  hearing  power.  There  is  nothing  marked  in  the  appearance  of  the  drum 
membranes.  He  totters  in  his  gait. 

INFLAMMATION  OF  THE  ACOUSTIC  NERVE  AND  LABYRINTH  FROM 

MENINGITIS. 

It  is  well  known  that  inflammation  of  the  base  of  the  brain 
may  extend  to  the  trunk  of  the  acoustic  nerve  and  to  the  laby- 
rinth. The  following  cases  are  examples  of  this  form  of  disease 
of  the  internal  ear  : 

CASE  1. — Meningitis—  Gradual  Deafness.— June  25,  1870.    W.  K  J ,  aged 

twenty-seven,  complains  of  increased  impairment  of  hearing.  Had  scarlet  fever 
when  a  child,  after  which  he  felt  a  diminution  in  the  hearing  power.  Last  winter 
had  congestion  of  the  brain  and  hemiplegia  of  left  side.  His  right  ear  became 
decidedly  worse  at  this  time.  He  has  recovered  from  the  hemiplegia.  There  is 


MENINGITIS.  ,653 

no  tinnitus  aurium.  The  hearing  distance  on  the  right  side,  0 ;  left,  }f.  Tun- 
ing-fork is  heard  better  on  right  side.  The  right  membrana  tympani  is  sunken, 
and  has  no  light  spot.  The  left  is  also  sunken,  and  exhibits  two  reflections  of 
light.  Inflation  of  the  ears  improves  the  hearing  on  the  left  side. 

CASE  II.— Basilar  Meningitis— Bilateral  Deafness. — April  30,  1872.     William 

E ,  aged  twenty-seven,  says  that  seven  weeks  ago  he  could  hear  well,  but 

after  an  attack  of  fever  attended  by  delirium,  he  found,  when  restored  to  con- 
sciousness, that  he  had  lost  his  hearing.  There  is  a  roaring  noise  in  the  left  ear, 
but  no  other  aural  symptom.  He  can  hear  the  watch  when  laid  upon  the' right  ear, 
but  not  at  all  upon  the  left.  The  tuning-fork  is  also  heard  more  or  less  distinctly 
in  the  right  ear.  The  right  drum-head  is  somewhat  sunken,  the  left  very  much  so. 

CASE  III. — Meningitis — Inflammation  of  Cerebral  Meninges  and  Labyrinth — Ex- 
posure to  Direct  Rays  of  the  Sun. — September  8,  1873.  Laura ,  aged  twenty- 
two  months.  The  mother  states  that  when  the  child  was  eight  months  old,  and 
teething,  she  was  unduly  exposed  to  the  direct  rays  of  the  sun,  and  was  there- 
upon suddenly  attacked  with  convulsions  and  was  ill  for  three  weeks  afterward. 
The  physician  in  charge  observed  that  she  was  losing  her  hearing,  and  the  mother 
thinks  that  she  has  not  heard  since  that  period.  The  drum-heads  are  both  very 
much  sunken  and  have  no  light  spot. 

CASE  IV. — Basilar  Meningitis — Effusion  about  Auditory  Nerve — Intermittent 
Character  of  Attacks — Epilepsy — Deafness — Recovery. — January  29,  1885.  Moses 

B ,  aged  twenty-nine,  merchant,  previous  to  July  last  heard  perfectly  well. 

He  has  had  intermittent  fever  at  different  times  for  two  years  ;  had  also  an  attack 
of  sunstroke.  In  July  he  lost  the  hearing  in  one  ear,  and  for  four  weeks  he  was 
deaf  with  both  ears.  After  a  course  of  counter-irritation  his  hearing  gradually 
returned.  He  has  taken  a  large  quantity  of  quinia.  Some  weeks  ago,  while  at 
Petersburg,  Va.,  his  hearing  power  again  failed,  and  at  the  present  time  he  can- 
not hear  words  at  all ;  even  the  ticking  of  the  watch  is  not  perceived.  He  can- 
not hear  the  tuning-fork  when  placed  upon  the  head,  but  feels  it  when  on  the 
teeth.  The  drum-heads  are  somewhat  opaque,  and  there  is  granular  pharyn- 
gitis. He  complains  of  a  severe  pain  in  the  top  of  his  head,  and  of  a  knocking 
sound  in  the  interior.  His  countenance  is  very  anxious,  appetite  poor,  but  he 
walks  well.  There  is  no  history  of  syphilis.  He  had  a  severe  fall  upon  his 
head,  striking  the  occipital  region,  when  he  was  seven  years  of  age.  I  saw  the 
patient  first  at  my  clinic  at  the  University  Medical  College,  and  the  next  day  at 
my  office  in  consultation  with  his  family  physician.  I  advised  iodide  of  potas- 
sium, but  I  did  not  see  him  again  for  two  months,  when,  at  the  instance  of  Dr. 
William  A.  Hammond,  he  called  upon  me,  and  to  my  great  delight  I  found  that 
he  could  now  hear  conversation  with  ease,  and  the  watch  at  twenty  inches  ; 
hearing  distance  f|  on  each  side.  He  had  been  under  Dr.  Hammond's  care  for 
about  four  weeks. 

Dr.  Hammond  treated  the  case  by  means  of  the  iodide  of 
potassium  mixed  with  the  bromide.  This  treatment  relieved 
the  cephalalgia  and  epilepsy.  Subsequently  he  administered 
arsenic  in  consequence  of  the  intermittent  type  of  the  epilepsy. 
The  hearing  power  was  suddenly  restored  on  one  side,  and  the 
other  soon  became  better  also. 

Through  the  courtesy  of  Dr.  H.   G.   Miller,  of  Providence, 


654.  DISEASE  OF  SPIRAL  CORD. 

have  been  furnished  with  the  following  interesting  history,  and 
1  was  also  afforded  the  opportunity  of  seeing  the  case  : 

CASE  V. — Meningitis — Inflammation  of  Both  Auditory  Nerves — Recovery  of 
One. — December  29,  1873.  H.  S ,  a  student  of  Trinity  College,  early  in  Octo- 
ber had  an  acute  affection  of  the  cerebral  meninges  and  of  internal  ear,  leaving 
him  totally  deaf  in  one  ear,  and  nearly  so  in  the  other.  I  saw  him  first  about  ten 
days  after  the  commencement  of  the  trouble.  His  condition  then  was  :  External 
and  middle  ears  perfectly  normal ;  subjective  noises  very  troublesome,  and  ex- 
treme giddiness  on  walking,  and  especially  on  attempting  to  go  down-stairs,  and 
also  on  turning  the  head  in  either  direction.  Hearing  distance  :  right  ear,  contact 
for  a  watch  of  30' ;  left  ear,  0.  Tuning-fork  heard  by  bone  conduction  in  right ; 
not  at  all  in  left.  I  put  him  on  bromide  and  iodide  of  potassium,  and  soon  began 
the  use  of  the  constant  current.  The  right  ear  improved  rapidly,  and  in  about 
five  weeks  hearing  distance  became  normal.  For  some  time  after  that,  however, 
through  the  two  octaves  of  the  piano,  from  middle  C  upward,  he  heard,  in  addi- 
tion to  the  note  struck,  another  less  than  a  semitone  above,  which  produced  a 
most  disagreeable  clang,  and  rendered  music  very  unpleasant  to  him.  I  then 
saw  Dr.  Blake  in  consultation  about  the  left  ear.  We  found  in  it  perception  for 
higher  sounds  than  normal,  and  that  this  perception  was  prolonged  by  the  con- 
tinued current ;  and  advised  the  continuance  of  the  electricity,  and  also  the  use 
of  valerianate  of  zinc  and  conium.  Since  that  time  there  has  been  but  little 
change.  He  has  at  times  heard  the  watch  faintly,  but  cannot  always  be  sure  of 
it.  The  auricle  of  the  affected  ear  was  quite  numb.  No  further  treatment  was 
advised. 

CASE  VI. — Meningitis — Deafness — Normal  Membranw  Tympani. — Sallie  A , 

aged  thirteen,  three  months  ago  was  attacked  with  severe  headache  and  vomiting; 
delirium  at  times,  but  generally  consciousness  retained.  In  three  weeks  the  fever 
subsided.  There  was  no  paralysis.  She  did  not  hear  well  after  being  ill  a  few 
days.  Was  attacked  on  Saturday,  and  on  Wednesday  it  was  observed  that  she 
did  not  hear  words,  even  when  spoken  very  close  to  her.  The  patient  com- 
plained then,  as  now,  of  severe  tinnitus  aurium  ;  does  not  hear  the  watch  at  all. 
The  tuning-fork  is  heard  well  and  naturally.  Jarring  sounds  hurt  her  head. 
There  are  no  marked  changes  on  the  membrana  tympani. 

INFLAMMATION  OF  THE  INTERNAL  EAR  FROM  DISEASE  OF  THE  SPINAL 
CORD  AND  MEDULLA,   TYPHOID   FEVER,  AND  SCARLET  FEVER. 

I  have  seen  several  cases  of  locomotor  ataxia  in  which  there 
was  considerable  impairment  of  hearing.  In  these  cases  the 
cause  has  not  usually  been  a  coincidental  catarrh  of  the  tym- 
panum, but  an  affection  of  the  acoustic  nerve.  The  tuning-fork 
was  heard  better  through  the  air,  the  voice  better  than  the  watch, 
noises  were  distressing,  and  the  hearing  was  made  worse  by 
inflation.  I  have  watched  one  such  case  for  some  eight  years, 
and  although  the  general  symptoms  of  the  patient  have  some- 
what increased — that  is,  his  locomotion  is  not  so  good,  and  his 
nutrition  is  more  impaired — the  hearing  power  remains  about  the 
same.  With  the  same  degree  of  disease  of  the  middle  ear,  he 
would  by  this  time  have  been  much  worse. 

Typhoid  fever  sometimes  produces  disease  of  the  middle  ear, 


SCARLET   FEVER — CEREBRO-SPJNAL   MENINGITIS.  655 

sometimes  of  the  labyrinth,  and  occasionally  of  both  parts  in 
the  same  subject.  There  is  apparently  an  anaemia  of  the  laby- 
rinth after  certain  cases  of  continued  fever,  for  while  the  symp- 
toms are  those  of  disease  of  the  nerve,  they  partially  recover  as 
convalescence  goes  on.  In  some  cases  it  is  possible  that  the  dis- 
ease of  the  labyrinth  is  caused  or  increased  by  quinine  which 
has  been  given  during  the  illness. 

Scarlet  fever  usually  causes  a  suppuration  of  the  middle  ears, 
and  no  further  disease,  but  in  some  rare  instances  the  inflamma- 
tion is  not  suppurative  and  attacks  the  labyrinth. 

CASE  I. — Scarlet  Fevei — Deafness — No  Change  in  the  Pharynx  or  the  Outer 

Ear. — January  28, 1870.    S.  M.  J ,  aged  five,  had  a  mild  attack  of  scarlet  fever 

when  he  was  eight  months  old  ;  the  mother  discovered  that  the  child  was  deaf 
four  months  afterward.  There  appears  to  be  no  hearing  power.  The  tuning- 
fork  causes  no  sensation.  The  pharynx  and  nares  are  in  a  healthy  state,  and  the 
membranse  tympani  show  no  changes. 

In  not  extremely  rare  instances,  as  it  appears  from  the  tables 
of  institutions  for  the  deaf  and  dumb,  pneumonia  causes  diseases 
of  the  internal  and  middle  ear.  I  once  saw,  in  consultation 
with  the  late  Professor  Little,  a  case  where  deafness  followed 
pneumonia,  which  followed  a  mild  attack  of  cerebro-spinal  men- 
ingitis. 

CASE  II. — Cerebro-Spinal  Meningitis  (?) — Pneumonia — Profound  Deafness — 

Sunken  Di-um-Head. — November  27, 1883.    Maggie  B ,  aged  five.    Dr.  Little's 

account  of  the  case  was  as  follows  :  ' '  This  child  was  taken  sick  about  two  weeks 
ago  with  symptoms  that  pointed  toward  cerebro-spinal  meningitis.  On  the  fifth 
day  these  symptoms  subsided  and  an  examination  showed  pneumonia  of  the  left 
lung.  Two  years  ago  sh.e  had  a  similar  attack.  She  now  seems  to  be  deaf." 
The  father  stated  that  the  child  had  been  deaf  for  a  week  ;  she  complains  of 
tinnitus  in  her  left  ear.  "When  the  child  was  taken  sick  she  had  fever  and  fre- 
quent vomiting.  The  latter  symptom  occurred  for  two  days.  On  the  fifth  day 
pneumonia  appeared.  She  recovered,  and  while  convalescing,  one  week  ago, 
deafness  came  on.  She  does  not  hear  the  voice  or  loud  sounds  conveyed  through 
the  air.  It  is  impossible  to  learn  whether  she  hears  the  tuning-fork  by  bone  or 
not.  Both  drum-heads  are  sunken,  and  the  left  is  congested  and  exhibits  two 
light  spots.  Treatment  was  of  no  avail.  On  June  4,  1884,  I  saw  her  again.  She 
was  deaf  to  all  sounds  through  the  air,  but  seemed  to  hear  the  vibrations  of  the 
tuning-fork  when  placed  upon  the  bones.  This,  I  think,  was  a  metastatic  in- 
flammation of  the  middle  and  internal  ears,  but  I  think  the  disease  began  in  the 
tympana,  and  that  some  degree  of  power  remained  in  the  nerve.  It  is  a  case 
which  throws  some  light  upon  the  nature  of  aural  disease  in  cerebro  spinal  men- 
ingitis. 

DISEASE    OF  THE   INTERNAL  EAR  FROM  PAROTITIS. 

Of  a  total  number  of  five  thousand  cases  of  aural  disease,  seen 
in  private  practice,  of  which  I  have  notes,  only  ten  seemed  to 
have  been  caused  by  parotitis.  Specialists  in  this  country  and  in 


656  DEAFNESS   FROM   PAROTITIS. 

Germany  have  seen  very  few  of  such  cases.  Of  late  great  in- 
terest has  been  shown  in  this  subject,  as  shown  by  cases  re- 
ported by  Buck,1  Brunner,"  Knapp,3  Moos,4  Harlan,  and  others,  but 
very  little  has  been  added  to  the  statements  of  Toynbee,  Hinton, 
and  myself,  made  by  the  first-named  author  in  his  text-book,  in 
1860,  by  Hinton,  in  1874,  in  his  "Questions  of  Aural  Surgery," 
and  by  myself  in  an  article  on  "Diseases  of  the  Internal  Ear,'' 
in  the  American  Journal  of  the  Medical  Sciences.  Toynbee  and 
Hinton,  and  lately  Dalby,  speak  of  disease  of  the  ear  after 
mumps  as  if  it  were  a  common  one.  In  this  they  differ  from 
the  German  and  American  authorities,  who  speak  of  it  as  a  rare 
affection.  Hinton  says  :  "  Next,  or  perhaps  equal,  in  frequency 
to  scarlatina,  in  this  respect,  stands  mumps,  which  has  an  effect 
on  the  nervous  apparatus  of  the  ear  which  has  as  yet  received 
no  explanation,  and  affords  no  clue  to  the  use  of  remedies  ; 
every  part  of  the  ear  being  normal,  so  far  as  examination  can 
extend,  but  the  function  is  almost  abolished.  '  But  some  cases 
(the  italics  are  mine)  of  damage  to  the  ear  from  mumps  present 
an  intermediate  character,  showing  clear  signs  of  a  tympanic 
disorder  mixed  with  the  nervous  symptoms.  The  similarity  of 
the  nerve  affection  that  follows  mumps  to  that  which  ensues 
upon  parturition,  is  very  striking;  and  the  resemblance  is  in- 
creased by  the  fact  that  quite  frequently  the  latter  affection  also 
is  accompanied  with  symptoms  of  a  catarrhal  character." 

After  all  that  has  been  written,  it  still  remains  doubtful  as 
to  how  the  ear  is  invaded,  and  whether  the  disease  is  generally 
a  primary  one  of  the  labyrinth  or  of  the  middle  ear.  That  it  is 
occasionally  at  least  a  disease  of  the  middle  ear,  the  last  of  the 
cases  reported  by  me,6  and  here  reproduced,  plainly  shows.  The 
first  cases  which  I  reported  were  observed  before  I  knew  the 
full  value  of  the  tuning-fork  in  diagnosis,  and  I  am  unable  to 
say  of  some  of  them  whether  they  are  cases  of  disease  of  the 
internal  or  middle  ear. 


CASE  I. — Parotitis — Deafness  of  One  Side — Patient  first  seen  Three  Years  after 
the  occurrence  of  the  Mumps. — H.  A.  H ,  aged  twenty-three,  student  of  medi- 
cine. Three  years  ago  the  patient  had  a  slight  attack  of  the  mumps.  During  it  he 
lost  the  hearing  of  the  right  ear.  Hearing  distance  :  R.,  **?$*  ;  and  L.,  ||.  The 
membrana  tympani  appears  to  be  normal.  There  is  considerable  tinnitus  aurium. 
The  patient  was  treated  through  the  Eustachian  tube  for  about  two  months. 

1  American  Journal  of  Otology,  vol.  iii.,  p.  203. 

2  Archives  of  Otology,  vol.  xii. ,  p.  102. 

1  Ibid.,  vol.  xi.,  p.  385.  4  Ibid.,  p.  13. 

*  Archives  of  Otology,  vol.  xii.,  p.  1. 


DEAFNESS   FROM   PAROTITIS.  657 

The  tinnitus  was  usually  diminished  for  an  hour  or  so  after  the  applications 
through  the  catheter. 

In  this  case  there  was  certainly  disease  of  the  middle  ear.  It 
will  be  observed  that  the  watch  was  heard  upon  the  mastoid 
process,  while  not  upon  the  meatus.  The  case  was  seen  in  1866, 
when  I  was  not  aware  of  the  value  of  the  tuning-fork  in  making 
a  differential  diagnosis  of  disease  of  the  middle  ear.  Yet,  from 
the  results  of  the  treatment,  I  am  confident  that  there  was  an 
affection  of  the  middle  ear  ;  also  the  nerve  may  have  been  af- 
fected. 

CASE  n. — Disease  of  Labyrinth  of  One  Side  after  Parotitis — Patient  first  seen 
One  Year  after  Loss  of  Hearing  occurred. — June  14, 1871,  MissB ,  aged  twenty- 
one.  Patient  states  that  she  had  the  mumps  one  year  ago.  After  recovery,  she 
observed  a  buzzing  sound  like  that  made  by  insects.  She  has  not  heard  with 
the  ear  since.  At  this  time  there  is  an  unpleasant  fulness  in  the  ear. 

The  hearing  distance  from  the  right  ear  is  normal.     From  the  left,  it  is  <&-. 

The  membranse  tympani  are  normal.  The  tuning-fork  is  heard  only  on  the 
right  side. 

The  patient  was  seen  again  in  September  of  the  same  year.  She  then  stated 
that  she  had  vertigo  occasionally.  In  other  respects  the  condition  was  the 
same. 

The  evidence  is  clear  that  the  labyrinth  was  the  chief,  if  not 
the  only,  seat  of  the  aural  disease  in  this  case.  The  foregoing 
cases  are  those  published  in  the  American  Journal  of  the  Medi- 
cal Sciences,  loc.  cit. 

CASE  III. — Disease  of  Labyrinth  of  Both  Sides  after  Scarlet  Fever,  Measles, 
and  Mumps — Patient  first  seen  Thirty -one  Years  after  Loss  of  Hearing  occurred. — 

September  15,  1873,  Henry  N.  X ,  aged  thirty-four.  The  patient  states  that 

when  two  or  three  years  old  he  had  the  measles,  scarlet  fever,  and  mumps  in 
one  year,  and  that  his  hearing  has  been  defective  ever  since.  He  never  had  any 
discharge  from  the  ears,  and  he  rarely  had  tinnitus. 

H.  D.,  R.  -^  ;  and  L.,  ^  (?). 

The  tuning-fork  is  heard  better  on  the  better  side.  The  right  drum-head  is 
somewhat  sunken.  The  left  one  looks  well. 

Inflation  of  the  middle  ear  produces  no  change  in  the  hearing  power. 

The  meagreness  of  the  history  does  not  enable  me  to  say 
whether  the  loss  of  hearing  was  observed  immediately  after  the 
attack  of  parotitis,  or  after  the  measles,  or  scarlet  fever.  The  ab- 
sence of  ulceration  at  any  time,  however,  inclines  me  to  believe 
it  to  be  a  true  case  of  loss  of  hearing  as  a  result  of  parotitis. 

CASE  IV. — Impairment  of  Hearing  of  Left  Ear,  occurring  during  attack  of 
Parotitis — Disease  of  Eight  Ear  had  occurred  previously  from  Scarlet   Fever- 
Patient  first  seen  about  Five  Months  after  attack  of  Mumps. — October  1,  1875, 
42 


658  DEAFNESS   FROM   PAROTITIS. 

Mrs.  J.  S.  C ,  aged  about  thirty-five.  The  patient  states  that  she  had  scar- 
let fever  at  the  age  of  eighteen.  She  has  suffered  from  greatly  impaii'ed  hearing 
on  the  right  side  ever  since.  Last  May  she  had  the  "  mumps."  During  the 
course  of  the  disease,  she  found  that  she  was  deaf  in  the  left  ear.  She  heard 
well  on  one  day,  and  the  next  day  she  found  herself  deaf.  There  was  no  pain 
in  the  ear,  and  no  discharge  from  it.  She  has  suffered  from  tinnitus  aurium 
since.  She  hears  the  watch  on  the  right  side  (on  that  of  the  ear  deaf  from  scar- 
let fever),  ^.  L.  ear  when  pressed  upon  the  mastoid,  /J-.  She  has  naso-pha- 
ryngeal  catarrh.  Both  dram-heads  are  of  good  color,  and  have  good  light  spots. 

The  diagnosis  made  was  disease  of  the  middle  ear  on  the 
right  side  and  disease  of  the  labyrinth  on  the  left.  The  grounds 
for  the  diagnosis  of  the  'labyrinthine  disease  are,  however,  not 
given,  except  in  the  statement  that  the  deafness  occurred  sud- 
denly, and  that  inflation  caused  no  improvement  in  the  hearing. 
Unfortunately,  I  do  not  remember  the  case  with  enough  clear- 
ness to  give  any  more  detailed  account  of  the  reasons  for  be- 
lieving that  the  ear  affected  by  scarlet  fever  was  chiefly  so  in 
the  middle  part,  while  the  other  had  a  lesion  of  the  nerve. 

CASE  V. — Impairment  of  Hearing  of  One  Side  after  Mumps  — Inspissated  Ceru- 
men— Hearing  Improved  after  its  removal — Patient  first  seen  Ten  Years  after  the 

Parotitis  had  occurred. — October  12,  1875,  C.  H.  T ,  aged  twenty-eight.    The 

patient  states  that  he  had  the  mumps  ten  years  ago.  After  that  he  observed 
that  the  watch  was  heard  better  in  front  of  the  right  ear  than  of  the  left.  He 
did  not  regard  the  condition  of  his  ear  very  much  until  last  summer,  when  he 
had  a  sore  throat  and  dyspepsia,  when  his  attention  was  again  called  to  his  ears. 
He  then  observed  a  drumming  noise  in  the  left  ear,  and  some  impairment  of 
hearing.  The  hearing  distance  was  found  to  be  R.,  ±$;  L.,  ^^-.  The  tuning- 
fork  was  heard  better  in  the  worse  ear.  The  pharynx  was  granular.  The  right 
drum-head  was  very  much  sunken,  and  there  were  opacities  in  it.  The  light 
spot  was  of  good  size.  The  left  membrana  tympani  was  covered  by  hard  wax. 
When  it  was  removed  the  drum-head  was  found  to  be  sunken,  and  it  had  no 
light  spot.  On  removal  of  the  cerumen,  the  hearing  distance  arose  from  •£§  to 
-&,  and  after  inflation  to  ^. 

The  history  and  examination  show  that  this  was  a  case  of 
disease  of  the  middle  ear.  It  is  probable  that  the  hearing  power 
was  only  slightly  impaired,  until  the  attack  of  inspissated  ceru- 
men, which  reducecl  it  so  much  as  to  call  the  patient's  attention 
to  it.  From  my  data,  I  believe  that  the  average  hearing  power 
of  the  side  affected  by  the  parotitis  was  fj>-. 

CASE  VI. — Double  Parotitis  followed  by  Absolute  Deafness — Patient  seen  Thirty- 
two  Days  after  occurrence  of  Deafness. — February  26,  1875,  Mabel  O ,  aged 

four  and  a  half.  The  patient  had  parotitis  about  thirty-two  days  ago.  She 
recovered  promptly.  Five  days  after  began  to  suffer  from  impairment  of  hearing, 
and  in  twenty-four  hours  she  became  deaf.  For  two  or  three  days  there  was 


DEAFNESS   FROM   PAROTITIS.  659 

some  unsteadiness  in  her  walk,  also  occasional  vomiting.  The  little  patient 
was  very  weak. 

The  patient  was  found  to  be  absolutely  deaf.  The  drum-heads  were  normal 
in  appearance.  No  improvement  resulted  from  treatment.  That  this  was  a  case 
of  disease  of  the  labyrinth  is  indisputable. 

CASE  VII. — Sudden  Deafness  of  One  Ear  after  Mumps — Patient  seen  a  Year 
after  the  Disease  occurred. — May  3, 1880,  R.  W.  H ,  of  Australia,  aged  twenty- 
three.  The  patient  states,  that  he  became  deaf  rather  suddenly  in  the  left 
ear,  after  an  attack  of  mumps  about  a  year  ago.  He  also  had  a  low  fever.  Just 
as  he  was  recovering  from  the  mumps,  he  found  that  he  was  hard  of  healing  on 
the  left  side.  He  could  hear  the  ticking  of  a*  watch  however.  He  has  remained 
hard  of  hearing  from  that  time.  H.  D.,  R.,  £f  ;  L.,  -£g.  The  bone  conduction  for 
tuning-fork  C  is  better  than  aerial  on  the  left  side.  Both  membranse  tympani 
are  opaque.  No  improvement  to  the  hearing  resulted  from  inflation. 

This  is,  I  think,  a  clear  case  of  disease  of  the  middle  ear  after 
parotitis ;  that  the  internal  ear  may  also  have  been  affected, 
will  not  be  denied.  Yet  the  probabilities  are,  that  the  disease 
was  situated  exclusively  in  the  middle  ear.  The  tuning-fork 
test  is,  I  think,  very  reliable  in  determining  the  situation  of  the 
lesion,  and  that  certainly  positively  indicated  disease  of  the 
middle  ear. 

CASE  VIII. — Parotitis  Three  Weeks  before — Deafness  Two  Weeks  since — Dizzi- 
ness for  One  Week — Dulness  of  Hearing  in  the  Right  Ear  also,  which  soon  passed 

away — Constant  Tinnitus. — June  25,  1881,  W.  D.  C ,  aged  forty-one,  sent 

to  me  by  Dr.  J.  W.  S.  Gouley. 

H.  D.,  R.,  5£  ;  L.,  /^  (?).  The  tuning-fork  is  heard  only  in  the  right  ear.  It 
is  not  heard  at  all  by  aerial  conduction  on  the  left  side. 

As  I  said,  in  discussing  this  case  in-  the  Archives,  although 
it  had  become  one  of  the  labyrinth  on  the  left  side,  it  may  have 
begun  in  the  middle  ear,  for  on  the  other  side  there  was  a  slight 
affection  of  the  middle  ear,  which  passed  away.  I  see  no  reason 
why  a  slight  affection  of  the  middle  ear  may  not  have  extended 
and  become  a  serious  affection  in  a  part  that  tolerates  only  a 
very  slight  lesion  ;  certainly  the  labyrinth  is  in  direct  communi- 
cation by  blood-vessels  with  the  tympanic  cavity,  which,  in 
turn,  through  the  auditory  canal  and  the  mastoid  process  is 
directly  connected  with  the  parotid  gland. 

CASE  IX — Parotitis  a  Year  before  Patient  was  seen  by  the  Writer — Hearing 

was  found  to  be  Impaired  soon  after. — March  11,  1882,  Janet  R ,  aged  twelve, 

sent  to  me  by  Dr.  J.  W.  S.  Gouley.  The  patient  had  parotitis  on  both  sides 
a  year  ago.  She  make  a  slow  recovery.  Her  hearing  was  found  to  be  impaired 
soon  after,  and  it  has  remained  so.  Her  general  health  is  fair. 

H.  D.:  R.,  it ;  L.,  -4V   She  cannot  say  in  which  ear  the  vibrating  tuning-fork 


6.60  DEAFNESS   FROM   PAROTITIS. 

is  heard,  when  placed  upon  the  forehead  or  teeth.  In  the  left  or  bad  ear  the 
bone  conduction  is  better  than  the  aerial. 

The  drum-heads  are  slightly  sunken  and  the  light  spots  are  small.  The 
hearing  is  diminished  immediately  after  inflation. 

The  patient  was  seen  a  few  times,  but  as  she  seemed  to  be  rather  worse  for 
treatment  of  the  middle  ear,  she  was  dismissed  unimproved. 

This  case  seems  to  me  to  be  a  clear  one  of  disease  of  the 
middle  ear,  although  I  will  not  undertake  to  say  that  there  was 
not  also  a  lesion  of  the  labyrinth.  The  fact  that  she  invariably 
became  worse  after  inflation  of  the  ear  inclines  me  to  think  so. 
But  the  fact  that  there  was  still  considerable  hearing  power  left 
in  the  ear,  inclines  me  to  the  belief  that  the  affection  was  pri- 
marily in  the  middle  ear. 

CASE  X. — Parotitis  on  -Each  Side — Chill  Fourth  or  Fifth  Day  after — Great  Im- 
pairment of  Hearing — Recovery  of  One  Side  after  Inflation  of  the  Middle  Ears — 

Improvement  in  the  Other. — Robert  B ,  aged  eight,  was  brought  to  me  by  his 

mother  on  April  24,  1882,  with  the  following  history  :  About  three  weeks  before 
he  was  attacked  with  mumps,  affecting  each  side.  On  the  fourth  or  fifth  day 
after  the  mumps  appeared,  he  had  chilly  sensations  one  evening,  probably  in 
consequence  of  the  lowering  of  the  temperature  of  the  room  in  which  he  was. 
The  next  day  he  had  a  high  fever ;  he  vomited ;  and  on  that  day  it  was  observed 
that  he  did  not  hear  well.  His  hearing  has  not  become  worse  since,  perhaps  he 
is  slightly  better.  He  was  treated  by  his  attending  physician  by  being  kept 
warm,  and  injections  of  a  warm  solution  of  chlorate  of  potash  were  daily  made 
to  his  throat.  He  did  not  improve  much,  however.  On  examination  it  is 
found  that  he  hears  loud  conversation  four  feet  behind  his  back.  Watch : 

R.,  YS  ;  L-,  irV- 

The  tuning-fork  is  heard  much  better  through  the  bones  than  through  the 
air,  on  each  side. 

The  right  membrana  tympani  is  of  good  color.  There  is  a  well-formed  light 
spot,  and  it  is  not  sunken.  In  the  left  membrana  the  light  spot  is  small. 

On  inflation  of  the  middle  ear  by  Politzer's  method,  the  hearing  distance  for 
the  watch  becomes  V»  on  the  right  side  and  4$  on  the  left,  while  the  voice  is 
now  heard  30  feet. 

The  patient  remained  under  observation  until  June.  He  was  treated  by  the 
use  of  Politzer's  method  of  inflation,  by  syringing  tl  naso-pharyngeal  space 
with  a  solution  of  chlorate  of  potash  ;  and  he  took  cod-liver  oil.  He  then  went 
abroad  with  his  parents.  He  was  directed  to  continue  the  treatment,  according 
to  circumstances,  during  the  summer.  When  he  returned  in  October,  he  could 
hear  general  conversation  with  ease,  but  on  the  right  side  the  watch  was  only 
heard  when  laid  upon  the  ear,  and  on  the  left  side  for  8  inches.  B.,  7\  ;  L.,  ^\. 
Voice,  30'.  About  a  month  afterward,  while  under  treatment,  after  the  escape 
of  quite  an  amount  of  dark-colored  viscid  material  from  his  nostrils,  the  patient 
said  that  sounds  were  unusually  loud.  On  examination  the  next  day  it  was 
found  that  the  hearing  distance  of  the  right  ear  was  -h  ,  and  the  left  1£ .  After 
inflation  the  hearing  distance  of  the  left  ear  became  normal,  while  the  right  re- 
mained unchanged.  At  the  present  time  the  patient  has  passed  through  an 


DEAFNESS   FROM   PAROTITIS.  661 

attack  of  inflammation  of  the  auditory  canal  and  tympanic  cavity  from  exposure 
to  cold,  but  his  hearing  has  become  normal  on  the  left  side,  while  it  remains 
impaired  on  the  right. 

February  9th.  — B.,  H  ',  L-»  if.  Voice  on  right  side,  with  normal  ear  closed, 
20  feet.  The  patient  is  still  under  treatment. 

October,  1890. — This  patient  has  now  become  a  young  man.  The  tuning-fork 
still  shows  that  the  situation  of  the  disease  is. in  the  tympanum  and  not  in  the 
labyrinth.  He  hears  conversation  well.  The  right  ear  is  still  better  than  when 
the  note  of  February,  1883,  was  made. 

This  case  of  impairment  of  hearing  after  mumps  is  a  very 
plain  one.  It  is  undoubtedly  a  case  of  disease  of  the  middle  ear 
and  not  of  the  nerve.  The  tuning-fork  and  the  results  of  treat- 
ment indicate  this.  Yet  he  had  symptoms  that  are  sometimes 
associated  with  an  affection  of  the  labyrinth.  It  is  quite  pos- 
sible that  such  an  affection  might  have  occurred  in  the  course 
of  any  acute  disease,  if  the  patient  were  exposed  to  a  chilling 
of  the  body.  I  am  confident,  however,  that  a  similar  process 
would  sometimes  be  found,  if  all  the  cases  of  impaired  hearr 
ing  occurring  after  mumps  were  observed  by  an  otologist  as 
early  as  this  one  was.  Most  of  the  cases  seen  by  an  aurist  are 
only  seen  some  time  after  their  occurrence,  when  the  history 
is  very  vague.  The  chief  symptom  is  said  to  be  sudden  deaf- 
ness. In  this  case  the  deafness  was  sudden.  Had  not  infla- 
tion come  to  its.  relief,  within  a  few  weeks,  this  might  have 
been  called  a  metastatic  case  ;  and  I  believe  the  labyrinth 
might  have  been  invaded  by  the  extension  of  the  inflamma- 
tory process  through  the  fenestrse.  I  see  no  reason  as  yet  to 
change  the  opinion  expressed  in  this  book,1  and  in  my  article, 
from  which  I  have  quoted,  that  in  some  cases  the  occurrence 
of  inflammation  of  the  ear  after  mumps  is  by  direct  exten- 
sion of  the  inflammation  to  the  auditory  canal,  middle  eary 
and  labyrinth.  That  there  may  be  a  form  of  so-called  meta- 
static inflammation,  I  do  not  deny.  Whether  the  channel  of 
communication  is  through  the  blood,  cannot  as  yet  be  deter- 
mined. To  my  mind  the  probabilities  lie  in  that  direction.  The 
theory  of  a  metastatic  inflammation  in  these  cases  is  usually 
not  based  upon  the  study  of  the  symptoms  at  the  time  they  oc- 
curred, but  upon  reasoning  from  analogy  :  for  example,  it  is  said, 
because  the  testes  and  breasts  are  sometimes  affected  by  meta- 
static inflammation,  therefore  a  disease  of  the  ear,  occurring 
after  mumps,  is  also  a  metastatic  affection.  Hinton,  as  is  seen 
by  the  quotation,  thought  a  catarrhal  inflammation  of  the  mid- 
dle ear  one  of  the  causes,  in  some  cases  at  least,  of  the  impair- 

1  Fourth  edition,  1878,  p.  539. 


662  INFLAMMATION   OF   MEMBRANOUS   LABYRINTH. 

« 

ment  of  hearing  often  seen  after  mumps.  As  I  have  shown,  my 
last  case  was  certainly  of  this  character. 

Every  one  admits  that  cases  of  extension  of  suppurative  in- 
flammation of  the  parotid  gland  to  the  external  auditory  canal 
are  not  uncommon.  Probably  this  extension  may  take  place 
through  the  fissures  of  Santorini.  If  a  suppuration  may  extend 
in  this  way,  why  not  a  catarrhal  process  ?  We  are  not  without 
examples  of  the  extension  of  an  inflammation  to  the  middle  ear 
from  the  auditory  canal  and  outer  layer  of  the  drum-head. 
Every  physician  at  all  accustomed  to  see  much  of  aural  disease 
has  seen  cases  where  from  a  draught  of  cold  air,  the  entrance  of 
cold  water  or  irritating  substances,  an  inflammation  has  been 
set  up  in  the  middle  ear  by  extension,  and  where  the  symptoms 
in  the  auditory  canal  have  passed  away  long  before  those  in  the 
middle  ear  have  been  relieved. 

As  a  result  of  my  observations  I  conclude — 

1.  An  acute  catarrh  of  the  middle  ear  may  occur  during  the 
course  of  mumps,  and  be  attended  by  fever  and  vomiting. 

2.  This  catarrh  may  extend  from  the  parotid  gland,  through 
the  auditory  canal  and  outer  layer  of  the  drum-head,  or  through 
the  mastoid  process. 

3.  An  affection  of  the  labyrinth  may  occur  simultaneously, 
or  by  extension  from  the  middle  ear. 

4.  It  is  probable  that  there  are  cases  where  the  disease  during 
the  course  of  mumps  is  transferred  to  the  labyrinth,  in  the  same 
manner  that  an  inflammation  sometimes  occurs  in  the  testes 
and  the  breasts,  but  this  cannot  be  considered  as  proven  until 
more  detailed  experience  is  furnished  of  cases  observed  a  few 
hours  after  the  impairment  of  hearing  occurs. 

Noyes  showed  an  interesting  case  of  deafness  after  mumps 
at  the  New  York  Ophthalmological  Society.  It  occurred  in  an 
adult.  The  loss  of  hearing  was  accompanied  by  a  staggering 
gait.  Only  one  ear  was  affected,  and  on  this  side  there  was  also 

metastatic  orchitis. 

• 

ACUTE   INFLAMMATION    OF    THE    MEMBRANOUS    LABYRINTH    MISTAKEN 
FOR  CEREBRO-SPINAL  MENINGITIS. 

As  has  already  been  said.  Voltolini l  was  the  first  writer  to 
call  attention  to  the  subject.  The  discussion  which  his  views 
have  excited  has  been  at  times  a  heated  one,  but  it  has  done 
great  good  in  calling  the  attention  of  general  practitioners  to  the 
possibility  of  mistaking  a  disease  of  the  ear  for  one  of  the  brain 
or  medulla. 

The  symptoms  of  epidemic  cerebro-spinal  meningitis,  as  given 

1  Monatsschrift  fiir  Ohrenheilkunde,  Jahrgang  I.,  No.  1. 


ACUTE   INFLAMMATION   OF    MEMBRANOUS    LABYRINTH.      663 

by  Clymer,1  are  "great  prostration  of  the  vital  powers,  severe 
pain  in  the  head  and  along  the  spinal  column,  delirium,  tetanic 
and  occasionally  clonic  spasm,  and  cutaneous  hypersesthesia, 
with,  in  some  cases,  stupor,  coma,  and  motor  paralysis,  attended 
frequently  with  cutaneous  haemic  spots."  Dr.  Clymer's  definition 
is  so  comprehensive  and  guarded  that  it  would  be  difficult  to  say 
that  the  symptoms  of  labyrinth-disease,  as  given  by  Voltolini, 
may  not  accord  with  those  of  cerebro-spinal  meningitis.  I  am 
inclined  to  think  that  Dr.  Clymer  has  made  his  definition  very 
comprehensive,  in  order  to  take  in  the  sporadic  cases.  Volto- 
lini regards  these  as  affections  of  the  labyrinth.  Voltolini  says,3 
"  The  children  are  attacked  quite  suddenly,  and  without  appar- 
ent cause ;  consciousness  is  soon  lost  as  a  rule,  but  the  head  is 
frequently  grasped  with  the  hands.  There  is  severe  fever,  a 
fixed  countenance.  They  bury  the  head  in  the  pillow.  There 
are  sometimes  slight  symptoms  of  paralysis,  but  they  are  never 
permanent ;  occasionally  there  is  vomiting.  Sometimes  the  dis- 
ease has  something  of  an  intermittent  character.  The  cerebral 
symptoms  soon  disappear,  but  the  patient  is  found  to  be  per- 
fectly deaf,  and  walks  with  a  staggering  gait." 

Voltolini  lays  particular  stress  upon  the  absence  of  facial  pa- 
ralysis in  these  supposed  cases  of  cerebro-spinal  meningitis,  and 
he  asks,  how  is  it  possible  to  have  an  exudation  in  the  medulla 
oblongata,  at  the  origin  of  the  auditory  nerve,  without  having 
at  the  same  time  one  of  the  facial,  when  the  fibres  of  the  two 
nerves  are  so  near  each  other  ?  Knapp  cannot  agree  with  Vol- 
tolini in  his  idea  of  primary  inflammation  of  the  membranous 
labyrinth,  and  has  discussed  the  subject  quite  fully  in  a  "Clini- 
cal Analysis  of  Inflammatory  Affections  of  the  Middle  Ear."1 
Knapp's  argument  against  Voltolini's  view  is  embraced  in  the 
following  question:  "If  the  same  complex  symptoms  in  some 
cases  produce  deafness,  in  others  blindness,  and  in  many  others 
neither,  Avhy  should  we  call  the  first  group  otitis  labyrinthica, 
mistaken  for  meningitis,  while  in  the  second  group  the  depen- 
dence of  the  ocular  affection  on  the  cerebro-spinal  disease  may 
be  demonstrated?"  It  is  no  answer  to  Voltolini's  arguments 
to  say,  as  has  been  said,  that  cases  of  inflammation  of  the  mem- 
branous labyrinth  are  "abortive"  cases  of  cerebro-spinal  menin- 
gitis. Voltolini  went  too  far  in  thinking  that  there  was  no  such 
disease  causing  deafness  as  cerebro-spinal  meningitis  ;  but  be- 
cause so-called  "spotted  fever"  does  exist,  and  transmits  dis- 

1  Reprint  from  the  American  edition  of  Aitken's  Science  and  Practice  of  Medicine, 
1872. 

8  Monatsschrift  fur  Ohrenheilkunde,  loc.  cit. 

3  Archives  of  Ophthalmology  and  Otology,  vol.  ii. ,  No.  1. 


664  ACUTE    INFLAMMATION    OF    LABYRINTH. 

ease  to  the  auditory  and  optic  nerves,  this  fact  furnishes  no 
evidence  that  primary  affections  of  the  nerve-trunks,  or  of  their 
expansions,  may  not  occur,  just  as  we  may  have  primary  optic 
neuritis.  But  here,  also,  gaps  in  our  knowledge  are  to  be  filled, 
a  task  that  must  be  performed  by  the  post-mortem  examinations 
made  by  the  practitioners  of  the  present  or  future. 

CASE  I. — Severe  Headache  and  Vomiting — Partial  Delirium — Deafness  in  a  Few 
Days — No  Paralysis — Recovery  from  all  Symptoms  but  Deafness. — May  3,  1873. 

Sallie  A ,  aged  thirteen.     Three  months  ago  this  child  was  attacked  with 

vomiting  and  pains  in  the  head.  She  became  only  slightly  delirious.  There  was 
no  paralysis  of  any  kind.  The  hearing  was  found  to  be  impaired  in  a  very  few 
days,  and  she  became  deaf  soon,  and  has  remained  so.  She  was  taken  sick  on 
Saturday,  and  on  Wednesday  she  heard  as  badly  as  now.  She  is  now  perfectly 
deaf,  but  concussions  hurt  her  ears.  She  walks  with  difficulty,  that  is,  the  gait 
is  staggering. 

CASE   II. —  Convulsions — Deafness. — March    25,    1872.      Martha   ,   aged 

eleven,  when  sixteen  months  old,  had  some  kind  of  convulsions,  and  since  has 
been  deaf.  Had  spoken  words  and  given  other  evidences  of  hearing  before 
this.  She  never  had  any  disease  of  the  head,  nor  discharge  from  the  ear.  She 
cannot  now  hear  the  ticking  of  a  watch,  nor  words  spoken  into  the  ear  ;  but  the 
vibrations  of  a  tuning-fork  are  plainly  perceived.  Both  membranse  tympani 
are  sunken. 

CASE  III.  — Inflammation  of  Labyrinth  from  Cold,  Induced  by  Lying  Down  while 

in  a  State  of  Perspiration.  —June  9, 1873.  George  O'B ,  aged  thirty-one,  agent, 

one  day  last  summer  lay  down  while  in  a  state  of  profuse  perspiration.  The  next 
day  he  observed  a  singing  noise  in  his  right  ear,  and  that  then  he  did  not  hear 
well  on  that  side.  There  were  also  darting  pains  across  his  head  and  the  back 
of  the  auricle.  Is  anxious  and  worried.  States  that  he  had  an  acute  inflamma- 
tion of  the  head  some  time  since.  Hearing  distance  :  right  ear,  0 ;  left,  if.  The 
membranse  tympani  show  no  signs  of  disease.  The  tuning-fork  is  heard  most 
distinctly  on  the  left  side. 

CASE  IV. — Pmn — Paralysis — Deafness. — Maria  L .  aged  three,  when  two 

years  and  a  month  old,  awoke  one  night  screaming  with  pain.  She  did  not  roll 
her  head,  or  become  unconscious,  but  lost  power  over  her  limbs,  and  had  general 
febrile  excitement.  She  was  ill  for  one  week,  but  it  was  two  months  before  she 
could  walk.  On  recovery  she  was  found  to  be  deaf,  and  is  now  almost,  if  not  en- 
tirely, devoid  of  hearing.  The  membranae  tympani  of  each  side  altered  in  cur- 
vature and  color. 

The  practitioner  will  judge  for  himself  as  to  how  much  in- 
flammation of  the  spinal  cord,  or  membranes  of  the  brain,  there 
is  in  such  cases  as  these. 

HEMORRHAGES  AND  EFFUSIONS. 

I  think  we  have  a  right  to  conclude,  from  the  clinical  history 
of  certain  cases,  that  a  hemorrhage  or  effusion  of  serum  into 
the  membranous  labyrinth  may  occur  without  any  well-defined 
cause.  Of  course,  in  atheromatous  degeneration  of  other  blood- 


HEMORRHAGES.  ;  665 

vessels  of  the  body,  we  may  also  suppose  that  such  a  hemor- 
rhage sometimes  occurs.  The  following  case  is  a  fair  type  of 
what  is  meant  by  hemorrhage  or  effusion  into  the  labyrinth  : 

Profound  Deafness  of  Both  Ears,  accompanied  by  Vomiting,  and  Loss  of  Equilib- 
rium, occurring  in  One  Night.  — A  healthy  young  man  aged  twenty-two  consulted 
me  at  the  instance  of  Dr.  Howard  Pinkney,  and  gave  the  following  history : 
His  occupation  was  that  of  a  wagoner.  He  was  attacked  one  night  with  vomit- 
ing and  dizziness,  and  in  a  few  hours  he  found  himself  completely  deaf  in  both 
ears.  He  could  not  hear  the  loudest  sounds.  The  nausea  and  dizziness  con- 
tinued for  about  two  weeks.  He  was  so  weakened  that  he  could  not  get  out  of 
bed,  but  he  retained  his  intellect  and  consciousness,  and  he  stated  that  there 
was  no  paralysis  of  any  part  of  his  body ;  he  could  lift  his  head,  his  arms,  move 
his  legs,  and  all  parts  of  his  body.  There  were  no  cases  of  cerebro-spinal  men- 
ingitis in  the  place  where  this  attack  occurred.  He  had  had  a  suppuration  in 
the  right  ear  some  years  before,  and  could  not  hear  well  from  that  ear  before 
this  attack.  It  is  now  three  months  since  his  deafness  came  on,  and  he  is  no 
better.  The  patient  is  ruddy  and  in  vigorous  health;  there  is  no  cardiac  or 
renal  disease.  He  has  not  had  syphilis.  He  walks  with  a  staggering  gait.  His 
intellect  is  unclouded.  He  has  tinnitus  aurium,  which  he  compares  to  the 
chirping  of  crickets.  The  vision  is  good.  He  is  still  dizzy  at  times.  An  ob- 
jective examination  showed  evidences  of  old  inflammation  in  the  right  membrana 
tympani,  but  there  was  no  inflammatory  action  going  on.  The  membrane  was 
transparent,  except  on  the  posterior  and  inferior  quadrant,  where  it  was  sunken 
and  adherent  to  the  wall  of  the  tympanic  cavity.  The  left 'membrana  tympani 
was  normal.  He  did  not  hear  the  watch  at  all,  nor  words  spoken  through  a  tube 
placed  in  the  external  meatus.  Air  enters  both  Eustachian  tubes.  The  tuning- 
fork  was  not  heard  better  when  the  ears  were  stopped. 
• 

I  think  there  is  no  reasonable  doubt  that  this  was  a  case  of 
hemorrhage  into  the  semi-circular  canals  and  the  cochlea.  I 
have  seen  several  such,  and  some  where  no  vomiting  occurred, 
but  sudden  deafness  with  absolutely  no  premonition.  We  are 
still  in  need,  however,  of  post-mortem  investigations  to  establish 
our  theories  founded  on  clinical  experience.  Inasmuch  as  such 
patients  do  not  usually  die  of  disease  of  the  labyrinth,  we  have 
not  the  same  facilities  for  clearing  up  a  diagnosis  that  we 
have  in  fatal  affections. 


INJURIES  OF  THE  OSSEOUS  LABYRINTH. 

In  the  chapter  upon  fractures  of  the  temporal  bone,  it  was 
seen  that  there  were  such  injuries  which  involve  the  tympanum 
only,  but  there  are  also  cases  in  which  both  the  osseous  and  mem- 
branous labyrinth  are  injured,  and  absolute  deafness  results. 

CASE  I. — Severe  Fall — Complete  Deafness  on  One  Side — Normal  Drum  Mem- 
branes.— September  H, 1865.  E.  M ,  aged  eleven,  five  years  ago,  or  when  six 


666  CONCUSSIONS. 

years  old,  had  a  severe  fall  down  stairs,  striking  his  head,  and  he  has  been  totally 
deaf  on  the  right  side  ever  since.  The  drum-heads  of  both  sides  are  normal.  He 
cannot  hear  the  ticking  of  the  watch  on  the  right  side,  except  when  upon  the 
mastoid  region,  the  meatus  being  closed.  The  air  is  easily  forced  through  both 
tubes  by  Politzer's  method  and  by  the  experiment  of  Valsalva,  but  no  improve- 
ment to  the  hearing  results. 

CASE  31. — Profound  Deafness  from  Blows  on  tJie  Head. — St.  Vincent's  Hos- 
pital, January  6,  1868,  a  patient  under  the  care  of  Dr.  J.  L.  Little.  This  man, 
aged  forty-five,  was  severely  beaten  in  a  fight  some  few  months  since ;  he  was 
unconscious  for  four  days,  and,  when  restored  to  consciousness,  was  perfectly 
deaf,  in  which  condition  he  still  remains.  His  gait  is  irregular ;  he  finds  great 
difficulty  in  keeping  his  head  in  an  erect  position,  even  when  supporting  it  with 
his  hand.  Marks  of  blows  are  still  traceable  over  one  eye  and  the  right  mastoid 
process.  There  seems  to  be  an  entire  absence  of  hearing  power,  as  found  by  all 
the  tests  capable  of  application.  He  seems  very  much  dejected,  but  is  well 
nourished.  Both  membranse  tympani,  especially  the  left,  appear  sunken,  and 
have  lost  their  transparency.  Air  enters  both  ears  by  Politzer's  method ;  the 
pharynx  is  in  fair  condition. 

I  think  we  may  fairly  conclude,  in  this  case,  that  the  blows 
produced  an  inflammatory  action  in  the  nerve,  as  well  as  in  the 
meninges  of  the  brain  and  the  parts  of  the  middle  ear,  and  this 
is  probably  the  ultimate  lesion  in  the  case  of  blows  and  falls. 
The  blood-vessels  are  perhaps  at  first  ruptured  ;  and  we  know, 
from  post-mortems  in  similar  cases,  that  suppurative  inflamma- 
tion of  the  labyrinth  and  basilar  meningitis  have  resulted.  In 
ophthalmic  practice  we  observe  cases  in  which  atrophy  of  the 
optic  nerve  follows  severe  injuries  upon  the  side  of  the  head ; 
but  this  atrophy  sometimes  presents  no  ophthalmoscopic  appear- 
ances at  first — or  at  least  very  few,  and  may  affect  but  one  nerve. 
In  other  cases,  hyperaemia  or  inflammation  precede  the  atrophy. 


CONCUSSIONS  OF  THE  LABYRINTH  (BOILER-MAKERS'  DEAFNESS). 

Workmen  employed  in  hammering  large  iron  plates,  such  as 
are  used  in  making  the  boilers  of  large  steam-engines,  are  very 
apt  to  lose  much  of  their  hearing  power.  So  many  of  these 
cases  are  seen  at  ear  infirmaries,  that  at  one  time  "Boiler- 
makers' Deafness "  figured  as  a  separate  disease  of  the  ear  in 
the  statistical  reports  of  one  of  our  institutions  where  aural  dis- 
ease was  treated.  Examination  of  such  cases  has  shown  me 
that  the  lesion  causing  the  impairment  of  hearing  and  deafness 
must  be  sought  for  in  the  labyrinth,  and  that  it  is  probably  due 
to  concussion  of  the  fibres  of  the  nerve  in  the  cochlea  and  semi- 
-circular  canals. 

Concussions  of  the  labyrinth,  from  cannonading,  such  as  are 


BOILER-MAKERS'  DEAFNESS.  667 

sometimes  experienced  by  soldiers  and  sailors,  the  impaired 
hearing  and  extreme  sensitiveness  of  the  ears  sometimes  ob- 
served in  telegraph  operators,  belong  to  this  class  of  labyrinth 
affections. 

There  can  be  no  hesitancy  in  believing  that  the  continual 
recurrence  of  a  kind  of  sound,  that  has  no  musical,  but,  on  the 
contrary,  an  unpleasant  character,  must  at  last  cause  a  hyperse- 
mia  of  the  ultimate  nerve-fibres  of  the  cochlea.  The  incessant 
shock  of  the  drum-head  by  the  blows  from  dozens  or  even  hun- 
dreds of  hammers  upon  vibrating  plates  must  agitate  these 
fibres  in  such  a  manner  as  to  finally  put  them  out  of  tune,  as 
certainly  as  the  constant  use  of  a  piano  will  at  last  loosen  its 
strings.  Clinical  experience  confirms  this  view,  and  my  own 
observations  and  investigations  in  reference  to  boiler-makers' 
shops  seem  to  demonstrate  the  following  facts  : 

I.  Boiler-makers  are  nearly  all  hard  of  hearing. 

II.  The  impairment  of  hearing  is  generally  attributable  to 
some  lesion  of  the  labyrinth,  probably  of  the  cochlea. 

Superadded  to  this  serious  trouble,  tympanic  or  middle  ear 
catarrh  or  impacted  wax  are  very  frequently  present,  but  these 
must  be  regarded  as  purely  coincidental.  Boiler-makers  are  con- 
stantly exposed  to  sudden  and  marked  changes  of  temperature, 
and  hence  often  catch  cold,  intensifying  and  increasing  by  this 
means  the  aural  affection. 

Should  a  man,  already  suffering  from  disease  of  the  middle 
ear,  begin  to  work  in  a  boiler-shop,  he  will,  of  course,  suffer  in 
a  much  greater  degree,  and  the  organ  be  more  susceptible  of 
additional  injury,  than  a  man  who  is  in  the  enjoyment  of  a 
sound  organ  of  hearing.  Dr.  D.  R.  Ambrose  has  shown  me  a 
case  which  confirms  this  view.  In  the  same  way,  a  telegraph 
operator  who  has  pharyngeal  catarrh,  and  consequently  a 
swelled  Eustachian  tube,  which  is  not  always  capable  of  per- 
forming its  proper  function,  will  be  more  sensitive  to,  and  suffer 
more  acutely  from,  the  concussions  of  the  instrument,  than  he 
who  has  a  healthy  throat.  The  existence  of  tympanic  and  tubal 
catarrh  will  cause  the  Eustachian  passage  to  be  less  pervious, 
or  even  at  times  entirely  closed ;  and  thus  aggravate  the  un- 
pleasant conditions  existing  when  waves  of  sound  that  have  to 
go  but  a  short  distance,  and  are  besides  inclosed  in  tubes,  and 
thus  increased  in  intensity,  impinge  upon  the  molecules  that 
make  up  the  ultimate  fibres  of  the  auditory  nerve. 

Those  who  work  inside  the  boilers  as  riveters,  and  who  thus 
have  shorter  waves  of  sound  striking  upon  their  ears,  lose  their 
hearing  power  most  completely,  as  is  evidenced  by  the  testi- 
mony of  all  old  boiler-makers.  It  is  not  easy,  in  the  absence 


668  BOILER-MAKERS'  DEAFNESS. 

of  post-mortem  investigations,  to  define  the  exact  nature  of  the 
lesion,  but  it  may  be  a  passive  congestion  of  the  contents  of  the 
cochlea. 

Boiler-makers  speak  in  graphic  language  of  the  effects  of  the 
din  upon  their  ears.  Said  one  of  them  tome  :  "Those  heavy 
hammers  jar  every  nerve  in  the  body."  They  do  not  find  much 
relief  from  wearing  cotton  in  their  ears,  except  when  first  enter- 
ing the  shop.  An  experienced  workman,  however,  told  me  that 
all  old  boiler-makers  had  learned  to  equalize  the  pressure  and 
reduce  the  shock  by  opening  the  mouth  frequently.  Of  course, 
by  this  procedure  they  open  the  Eustachian  tube  more  freely. 

My  reasons  for  believing  that  the  lesion  in  these  cases  is- 
situated  in  the  nerve  predominantly,  are  that  the  aerial  conduc- 
tion is  always  louder  than  the  bone  conduction,  as  tested  by 
the  tuning-fork  "  0s,"  and  that  it  is  heard  longer  than  by  bone 
conduction.  The  only  apparent  exceptions  to  this  rule  were 
those  in  which,  in  addition  to  the  lesion  of  the  acoustic  nerve, 
there  was  also  inspissated  cerumen.  When  the  wax  was  re- 
moved, however,  and  the  cases  were  transposed  into  their  proper 
place,  of  diseases  of  the  acoustic  nerve  produced  by  concussion, 
the  tuning-fork  was  heard  through  the  air  louder  and  longer 
than  through  the  bone.  I  consider  all  the  other  tests  that  we  as 
yet  have,  for  the  differential  diagnosis  of  affections  of  the  mid- 
dle and  internal  ear,  as  so  much  inferior  to  this,  although  of 
great  corroborative  value,  that  I  am  constrained  to  consider  all 
observations  upon  boiler-makers  that  have  not  been  made  in 
this  way,  as  so  defective  as  to  tell  nothing  of  the  true  seat  of 
the  disease.  In  addition  to  the  test  by  the  tuning-fork,  the  ex- 
amination of  the  hearing  power  by  the  voice  shows  that  these 
patients  hear  better  in  a  quiet  place  than  in  a  noise.  As  has 
been  suggested  by  many  writers,  there  is  no  doubt  that  some- 
thing might  be  done  to  avert  the  consequences  of  those  concus- 
sions in  producing  disease  of  the  acoustic  nerve,  if  workmen 
could  be  induced  to  wear  ear  protectors  ;  but  from  some  reason  or 
other,  they  are,  as  a  rule,  quite  averse  to  wearing  cotton  in  their 
ears,  or  any  contrivance  for  protecting  their  ears  from  the  effect 
of  a  great  and  constant  concussion.  Almost  all  boiler-makers 
say  that  they  were  deafer  at  first  than  after  they  had  become 
accustomed  to  the  occupation  ;  and  they  all  say  that  they  hear 
better  after  a  period  of  rest,  for  example  from  Saturday  to  Mon- 
day. 

That  excessive  sound  must  necessarily  be  as  harmful  to  the 
nerve  of  hearing,  as  is  excessive  light  to  that  of  sight,  is  a 
natural  deduction  from  our  knowledge  of  the  effects  of  the 
waves  that  produce  those  two  senses,  and  all  experience  con- 


BOILER-MAKERS'  DEAFNESS.  669 

firms  the  belief  that  there  may  be  an  acoustic  neuritis  produced 
by  noise,  as  well  as  an  optic  neuritis  caused  by  exposure  to  a 
glare. 

The  cases  upon  which  my  conclusions  as  to  boiler-makers' 
deafness  depend  are  as  follows  : ' 

CASE  I. — Boiler-maker  Twenty  Years — Disease  of  the  Acoustic  Nerve. — John. 

F ,  aged  thirty-five.     Has  been  in  the  business  for  twenty  years.     Hearing 

was  good  when  he  began ;  began  hearing  noises  in  his  ears  ;  then  became  hard 
of  hearing  gradually.  Cannot  now  hear  a  lecture.  Does  not  hear  better  in  the 
noise  of  the  shops,  but  he  assists  his  ears  by  watching  the  lips  of  those  speaking 
to  him.  Was  most  deaf  after  working  in  a  boiler.  Did  not  use  cotton,  because 
it  made  him  worse  when  removed.  Hissing  tinnitus  all  the  time.  Hearing :  B., 
?P8,  a«5rial  conduction  best ;  air  duration,  23  seconds  ;  bone,  11  seconds.  L.,  ?3?, 
aSrial  conduction  best ;  air  duration,  20  seconds  ;  bone,  9  seconds.  M.  T.  :  E., 
good  color,  good  light  spot,  not  sunken  ;  L.,  sunken,  two  light  spots,  good  color. 
.Says  that  he  has  never  had  catarrh. 

CASE  II. — Boiler-maker  Thirty  Years — Disease  of  Acoustic  Nerve. — X.  Y- , 

forty-six  years  of  age.  Has  been  in  the  business  for  thirty  years.  Hearing  was 
good  when  he  began  his  work.  Now  cannot  hear  well  when  spoken  to.  Thinks 
he  hears  better  in  a  noise,  because  people  speak  louder.  No  pain  at  any  time, 
but  has  noises,  and  hearing  failed  gradually.  Has  used  cotton,  but  does  not 
like  it.  Hearing:  E.,  ^,  aerial  conduction  best;  watch  not  heard  on  mastoid  ; 
aerial  conduction,  26  seconds ;  bone,  12  seconds.  L.,  —g,  aerial  conduction  best ; 
watch  not  heard  on  mastoid  ;  aerial  conduction,  21  seconds  ;  bone,  8  seconds. 
M.  T. :  E.,  opaque,  no  light  spot,  vascular  along  handle  of  the  malleus;  L., 
opaque,  sunken,  no  light  spot.  Pharynx  sound. 

CASE  III. — Boiler-maker  Twenty-four  Years — Disease  of  Nerve — One  Side  of 
the  Middle  Ear  and  Nerve  on  the  Other. — Forty-seven  years  of  age.  Has  been  in 
the  business  twenty -four  years.  Hearing  was  good  before  he  began  it.  Sissing 
tinnitus.  Deafness  came  on  gradually,  but  was  worse  when  he  was  "holdnig 
on";  no  pain.  Cotton  did  no  good.  Hearing :  E.,  &,  aerial,  but  no  bone  con- 
duction ;  duration  of  aerial  conduction,  6  seconds ;  bone,  0.  L.,  4U«,  aerial,  feels 
something ;  bone  conduction  distinct ;  duration  of  aerial  conduction,  0  ;  bone, 
12.  M.  T.  :  B.,  opaque  rim,  vascular  malleus,  no  light  spot ;  L.,  good  color, 
vascular  malleus,  no  light  spot.  Pharynx  catarrhal ;  uvula  elongated. 

CASE  IV. — Boiler-maker  Twenty-four  Years — Disease  of  Acoustic  Nerves. — 
Fifty-one  years  of  age.  Has  been  in  the  business  twenty-four  years ;  previous 
to  which  his  hearing  was  very  sharp,  now  is  very  poor.  Sissing  tinnitus  ;  does 
not  hear  any  better  in  the  shop  or  car.  Wears  cotton  at  times.  No  pain  in  ear. 
Health  good.  Voice  at  four  feet.  Hearing:  E.,  -J^,  aerial  feeble;  no  bone 
conduction  ;  aerial  duration,  5  seconds  ;  bone,  0.  L.,  •£$,  aerial  feeble  ;  no  bone 
-conduction  ;  aerial  duration,  6  seconds ;  bone,  0.  M.  T.  :  E.,  opaque  (wax)  ; 
;L.,  opaque  on  periphery,  no  light  spot.  Pharynx  in  good  condition. 

1  Reprinted  from  Archives  of  Otology,  vol.  xii.,  p.  111. 


670  BOILER-MAKERS'  DEAFNESS. 

CASE  V. — Boiler-maker  Twelve  Years — Disease  of  Acoustic  Nerve. — Agecl 
twenty -five.  Has  been  in  the  business  twelve  years.  Hearing  is  good ;  no  pain 
or  noises.  Hearing  :  B.,  &,  aerial  best ;  aerial  duration,  21  seconds  ;  bone,  7 
seconds.  L.,  i?,  aerial  best;  aerial  duration,  20  seconds;  bone,  10  seconds. 
M.  T. :  B.,  good  light  spot,  opaque  on  periphery  and  above ;  L.,  good  light 
spot,  opaque.  Catarrhal  pharynx. 

CASE  VI. — Assistant  in  Boiler-shop  for  One  and  a  Half  Year. — Works  ten 
hours  per  day.  Thinks  his  hearing  is  good  enough.  Hears  ordinary  conversa- 
tion with  his  face  away  from  the  speaker  about  twenty  feet.  Hearing  :  B.  E., 
aerial  conduction  louder;  air  duration,  10  seconds;  bone,  5  seconds.  L.,  J4f, 
aerial  conduction  louder ;  air  duration,  16  seconds  ;  bone,  4  seconds.  M.  T.  : 
B.,  small  light  spot,  opaque  ;  L.,  small  light  spot,  vascular.  Pharynx  healthy. 

CASE  VII. — Boiler-maker  Thirteen  Years  —  Disease  of  Middle  and  Internal 
Ears. — Has  been  in  the  business  thirteen  years.  Hearing  always  good.  Never 
protected  nis  ears.  Had  a  pain  in  left  ear  once,  but  no  discharge.  Whispers 
heard  by  others  not  heard  by  him.  Does  not  hear  better  in  noise.  Hearing  : 
B.,  ^,  bone  conduction  best ;  aerial  duration,  10  seconds ;  bone,  9  seconds. 
L.,  ^,  bone  conduction  best;  aerial  duration,  13  seconds;  bone,  7  seconds. 
M.  T. :  B.,  good  color  and  light  spot;  L.,  sunken,  opaque,  small  light  spot. 
Tonsil  enlarged.  Pharyngitis. 

CASE  VIII. — Aged  Eighteen  —  Boiler-maker  for  Fifteen  Months — Disease  of 
Acoustic  Nerve. — Has  been  in  business  fifteen  months.  Hearing  good  when  ho 
came.  Not  so  good  now.  Hissing  tinnitus.  No  pain.  Does  not  hear  better 
in  noise.  Hearing:  B.,  -/„-,  aerial  best;  aerial  duration,  12  seconds;  bone,  9- 
seconds.  L.,  H,  aerial  best;  aerial  duration,  14  seconds;  bone,  7  seconds.  M. 
T. :  B.,  small  light  spot,  prominent  short  process ;  L.,  no  light  spot,  prominent 
short  process  Slight  pharyngitis. 

CASE  IX. — Thirty  Years  a  Boiler-maker — Inspissated  Cerumen — Disease  of 
Acoustic  Nerve. — Aged  forty-nine.  This  subject  is  what  is  technically  called  a 
"holder-on."  His  duties  keep  him  inside  of  the  boiler  holding  on  to  the  rivets. 
The  shock  of  sound  is  much  greater  here  than  in  the  open  air  of  the  shop. 
Thirty  years  a  boiler-maker.  Three  and  a  half  years  in  navy.  Ears  were  good 
when  he  went  into  the  present  business.  Hears  better  when  he  gets  away  from 
noise.  Voice,  6'.  Watch,  VV,  each  side.  Tuning-fork :  B.  E. ,  aerial  louder,  8  ; 
bone  louder,  3.  L.  E.,  aerial  louder,  8 ;  bone  louder,  4.  Inspissated  cerumen 
on  each  side.  After  removal  of  large  plugs  of  very  hard  wax,  H.  D.  for  the  voice 
increased  to  18',  and  the  watch  was  heard,  when  pressed  on  each  side,  ips.  The 
dui-ation  of  the  aerial  conduction  was  increased,  but  no  change  in  the  intensity 
with  which  it  was  heard. 

It  is  interesting  to  note  in  this  case  that  the  aerial  conduc- 
tion was  louder  and  longer,  even  when  the  ear  was  plugged 
with  wax.  This  shows  a  more  marked  lesion  of  the  nerve,  than 
the  other  cases  in  which  inspissated  cerumen  was  found — for  in 


BOILEK-MAKEKS'    DEAFNESS.  671 

these  latter  the  bone  conduction  was  better  until  the  wax  was- 
removed,  when  the  aerial  conduction  was  found  to  be  as  is  usual 
in  those  suffering  from  boiler-makers'  deafness. 

CASE  X. — Boiler-maker  Thirty-one  Years — Disease  of  Acoustic  Nerve. — James 

L ,  forty-seven.      Boiler-maker  thirty-one    years.      First    job  was  that  of 

riveter,  and  in  twenty  days  could  not  hear  well ;  tinnitus  like  bees ;  never  had 
earache  ;  healthy  ;  rheumatism  ;  voice  20 '.  Hearing  :  B.,  -/„- ;  L.,  -/„-,  aerial 
conduction  better  each  side ;  E.,  aerial,  12  seconds ;  bone,  8  seconds  ;  L.,  aerial, 
9  seconds;  bone,  9  seconds.  M.  T.  :  E.,  good  light  spot,  good  lobe;  L.,  good 
light  spot,  good  lobe.  Both  opaque  on  periphery.  Healthy  pharynx. 

CASE  XI. — Boiler-maker  for  Twenty  Years — Inspissated  Cerumen  removed  from 
Both  Sides — Disease  of  Acoustic  Nerves. — Aged  thirty-nine.  Has  been  twenty 
years  in  the  business.  Ears  were  sound  when  he  began ;  had  an  occasional 
earache  as  a  boy.  He  can't  hear  a  whisper;  does  not  hear  well  in  a  boiler-shop. 
Watches  the  mouth  and  gestures.  Hears  the  voice  in  a  quiet  room  40'.  Watch: 
E.,  -4a8- ;  L.,  -&-.  E.  side  the  aerial  conduction  is  better  ;  on  the  left  the  bone  con- 
duction is  better.  E. ,  aerial  conduction  is  heard  12  seconds ;  bone,  6  seconds. 
L.,  a6rial  conduction  is  heard  12  seconds;  bone,  8  seconds.  Pharynx  is  sound. 
Inspissated  cerumen  is  found  on  each  side.  After  it  is  removed  the  watch  is 
heard  better  on  each  side  ;  e.g.,  E.,  ^  ;  L.,  /ff.  Eelative  distinctness  of  bone 
and  aerial  conduction  not  changed.  Duration  of  the  sound  about  as  before. 

CASE  XH. — Boiler-maker  Twenty-five  Years — Inspissated  Cerumen  Both  Sides 
— Disease  of  Acoustic  Nerves.  — Aged  forty-three.  This  man  has  been  a  boiler- 
maker  twenty-five  years.  He  had  good  hearing  when  he  began  his  work. 
Never  had  an  earache.  Hears  the  voice  in  a  quiet  room  30 '.  Watch  -~"g-  on 
right  side,  ^g  on  left  side.  E.  side,  bone  conduction  much  more  distinct ;  L.  side, 
the  same.  Duration:  E.,  aerial  conduction,  5  seconds  ;  bone,  12  seconds  ;  left 
side,  aerial,  14  seconds  ;  bone,  11  seconds.  Inspissated  cerumen,  each  side,  re- 
moved. After  removal  of  wax  watch  was  heard  -430-  and  -4Aj  on  the  right  and  left 
sides  respectively,  instead  of  J^.  and  ^.  The  aerial  conduction  became  better  in 
each  ear.  Duration  as  follows:  E.,  aerial,  18  seconds;  bone,  13  seconds;  L., 
aerial,  22  seconds  ;  bone,  12  seconds. 

As  is  seen,  the  peripheric  trouble  (inspissated  cerumen) 
masked  the  disease  of  the  acoustic  nerve  in  this  case,  but  when 
the  wax  was  removed  the  lesion  of  a  boiler-maker's  ear  was 
found  to  exist. 

In  Case  VII.  the  bone  conduction  was  decidedly  louder  than 
the  aerial,  but  the  tuning-fork  was  heard  much  longer  through 
the  air  than  through  the  bone.  The  left  drum-head  was  sunken 
and  opaque,  and  there  was  considerable  throat  trouble.  From 
these  data  I  conclude  that  there  is  disease  of  the  middle  as  well 
as  of  the  internal  ear  in  that  case. 


672 


BOILER-MAKERS'  DEAFNESS. 


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BOILER-MAKERS'  DEAFNESS.  673 

From  all  the  observations  I  have  been  able  to  make  upon  this 
subject,  I  think  I  am  justifiable  in  drawing  the  following  con- 
clusions : 

1.  The  hearing  power  of  persons  working  in  such  a  din  as 
that  of  a  boiler-shop  invariably  becomes  impaired. 

2.  The  lesion  caused  by  this  occupation  is  one  of  the  mem- 
branous labyrinth,  or  of  the  trunk  of  the  acoustic  nerve. 

3.  Persons  thus  affected  do  not  hear  better  in  a  noise.     Their 
hearing  power  is  better  in  a  quiet  place,  and  becomes  better 
after  prolonged  absence  from  the  exciting  cause  of  their  im- 
paired hearing. 

4.  The  cases  of  inspissated  cerumen,  catarrh  of  the  middle 
ear,  occurring  among  boiler-makers,  are  such  as  occur  among 
those  employed  in  various  occupations  and  only  mask  and  com- 
plicate the  fundamental  primary  trouble,  so  long  known  as 
boiler-makers' '  deafness. 

Other  occupations  of  a  similar  nature,  that  is,  occupations 
amid  continuous  concussions,  undoubtedly  cause  the  same  le- 
sion. A  recent  visit  to  an  establishment  where  two  engineers 
were  employed  for  the  production  of  electric  light,  showed  me 
that  since  they  had  been  engaged  in  an  occupation  exposing 
them  to  the  sound  of  regular  concussions  from  the  striking  of 
metallic  plates  together,  they  had  become  somewhat  hard  of 
hearing. 


CASES    OF  TINNITUS    AURIUM    AND    IMPAIRMENT     OF   HEARING    FROM 
OTHER  KINDS  OF  CONCUSSIONS. 

CASE  I. — Tinnitus   Aurium,  without  Impairment  of  Hearing,  Occurring  from 
Listening  to  a    Telegraph  Instrument — Hypercemia  of  Acoustic  Nerve  ? — W.   G. 

B ,  aged  thirty-seven,  states  that  he  has  been  a  telegraph  operator  for  about 

twenty  years,  and  that  he  has  had  tinnitus  aurium  for  about  two  years.  Hear- 
ing distance  :  right,  £f ;  left,  ||.  Both  membranse  tympani  have  good  light 
spots ;  there  is  some  granular  pharyngitis.  The  patient  is  confident  that  the 
vibrations  of  the  telegraphic  instrument  have  caused  the  noise  in  his  ears.  The 
sound  of  the  instrument  is  very  unpleasant  to  him,  and  he  is  obliged  to  protect 
his  ears,  while  at  work,  by  cotton  plugs.  Indeed,  his  ears  have  got  into  such  a 
sensitive  condition  that  jarring  sounds  of  any  kind  are  extremely  annoying  to 
him.  The  patient  is  in  good  general  health. 

CASE  II. — Impairment  of  Hearing  of  One  Side,  ascribed  to  Occupation  as  Tele- 
graph Operator. — May  4,  1870.     Mr.  B ,  aged  twenty-seven,  about  a  year  ago 

1  For   an  account  of  my  first  examination  '  of  the   hearing  of  boiler  -  makers,  the 
reader  is  referred  to  this  work,  edition  of  1877,  and  to  the  American  Journal  of  the 
Medical  Sciences,  1874,  vol.  Ixviii.,  p.  380. 
43 


674  CONCUSSIONS   OF   ACOUSTIC   NERVE. 

discovered  that  the  hearing  power  of  his  left  ear  was  somewhat  impaired.  Three 
months  ago  he  was  troubled  with  a  continuous  noise  in  that  part  of  his  head. 
He  is  a  telegraph  operator,  and  has  been  accustomed  to  use  his  left  ear— leaning 
his  head  over  the  machine  on  that  side  and  intently  listening.  He  believes 
that  this  is  the  cause  of  his  loss  of  hearing.  The  drum-heads  look  very  much 
alike,  both  exhibiting  peripheral  opacities,  but  in  other  respects  having  a  normal 
appearance.  The  pharynx  and  nares  seem  to  be  healthy.  Inflation  of  the  ears 
has  no  effect  upon  the  hearing.  The  watch  is  not  heard  at  all  on  the  affected 
side,  nor  is  the  tuning-fork. 

CASE  HI. — Exposure  to  Cannonading — Tinnitus — Impairment  of  Hearing  for 

the  Watch,  but  not  for  Ordinary  Conversation. — February  11,  1868.    W.  B.  X , 

aged  twenty-five,  observed  some  difficulty  in  hearing  ten  years  ago ;  and,  after 
being  exposed  on  a  gunboat  to  severe  cannonading,  while  an  officer  in  the  navy, 
he  became  worse,  although  he  has  scarcely  any  tinnitus  aurium.  Hearing  dis- 
tance :  right  ear,  -/»  ;  left  ear,  -&.  Both  drum-heads  appear  to  be  normal.  Air 
enters  each  Eustachian  tube  freely,  but  inflation  causes  no  improvement  in  the 
hearing  power. 

I  have  had  ample  opportunity  to  test  the  hearing  power  of 
this  patient  in  conversation,  which  he  hears  so  well  (in  spite  of 
the  fact  that  his  power  of  hearing  the  watch  is  much  impaired), 
that  he  has  never  been  considered,  by  any  but  his  most  intimate 
friends,  as  very  hard  of  hearing.  Persons  who  can  hear  the 
watch  no  better  than  he,  are  usually,  if  not  always,  very  much 
troubled  to  hear  conversation,  even  when  addressed  especially 
to  them  ;  and  yet  the  patient  in  question  can  join  in  general  con- 
versation carried  on  in  an  ordinary  tone,  and  can  hear  lectures, 
aiid  so  forth,  with  perfect  ease. 

My  friend  Dr.  Rhoades,  surgeon  in  the  United  States  Navy, 
informed  me  that,  during  an  experience  in  several  naval  en- 
gagements large  and  small,  during  our  late  civil  war,  he  never 
saw  a  rupture  of  the  membrana  tympani  from  cannonading. 
He  has  seen  sailors  who  said  they  were  hard  of  hearing  from 
cannonading.  These  men  usually  complained  of  tinnitus.  Some 
of  them  got  better,  and  some  worse.  Sailors  usually  keep  the 
mouth  open  during  the  firing. 

The  following  case  also  illustrates  the  effect  of  concussion  of 
the  labyrinth.  It  is  possible  that  an  injury  of  the  labyrinth  more 
readily  occurs  when  the  membrana  tympani  is  in  a  relaxed 
condition,  as  was  probably  the  case  in  this  instance,  the  sub- 
ject being  surprised  by  the  wave  of  air  that  unexpectedly  forced 
upon  the  endolymph.  Any  one  who  has  received  an  unexpected 
whisper  in  the  auditory  canal,  may  remember  how  long  a  tin- 
nitus aurium  continued  which  it  seemed  to  produce. 

CASE  IV. — Loss  of  Hearing  from  a  Kiss  upon  the  Ear. — Mrs.  H ,  aged 

forty-two,  seen  through  the  kindness  of  Dr.  O.  B.  Douglas.     Last  winter  (1878), 


CONCUSSIONS   OF  ACOUSTIC   NERVE.  675 

her  husband  came  up  behind  her  as  she  sat  reading,  and  kissed  her  suddenly 
upon  the  right  ear,  taking  her  completely  by  surprise.  She  suffered  a  great  shock 
and  had  a  roaring  in  the  ear  for  some  time.  The  incident  made  her  very  ' '  ner- 
vous "  for  two  or  three  weeks  afterward.  During  the  past  summer  she  was  told 
by  her  relatives  that  she  was  becoming  deaf  on  the  right  side.  She  paid  no  at- 
tention to  it  until  six  weeks  ago,  when  she  tried  her  right  ear  with  her  watch  and 
found  she  could  not  hear  it.  She  gives  satisfactory  evidence  of  having  heard  a 
whisper  well  with  the  right  ear  during  last  winter  and  spring.  Has  had  occa- 
sional tinnitus  during  the  past  few  months  after  taking  cold.  Enjoyed  music 
very  much  formerly,  but  does  not  now.  The  piano  practice  of  the  children  at 
home  annoys  her.  Whistling  is  particularly  disagreeable.  All  noises  disturb 
her  somewhat,  so  that  she  has  "felt  afraid  that  she  was  becoming  nervous." 
General  health  is  good.  Menstruates  regularly.  No  cardiac  trouble  detected. 
Father  died  of  paralysis. 

H.  D.,  K.,  /0-  ;  L.,  ft. 

Tuning-fork  on  teeth  or  vertex  seemed  louder  in  the  left  ear.  Is  slightly  in- 
tensified in  right  by  plugging,  but  much  more  in  left.  Aerial  better  than  bone- 
conduction  on  each  side. 

The  drum-heads  are  about  alike  and  show  nothing  to  account  for  deafness. 
Air  enters  the  right  drum  by  both  catheter  and  Politzer's  method,  but  does  not 
alter  the  hearing.  All  notes  of  the  piano  are  heard,  but  she  says  they  do  not 
sound  "  clear,"  even  with  both  ears  open.  Dr.  Douglas  examined  the  naso- 
pharyngeal  space  and  the  mouths  of  the  Eustachian  tubes  and  found  nothing 
abnormal. 

This  seemed  to  be  a  case  of  deafness  from  affection  of  the 
labyrinth,  with  no  apparent  cause  except  the  kiss  upon  the  ear. 
The  concussion  from  the  kiss  may  have  caused  the  loss  of  hear- 
ing at  once ;  or,  as  seems  more  likely,  it  may  have  produced 
changes  in  the  labyrinth,  which,  in  combination  with  the  general 
nervous  shock,  served  as  a  foundation  for  a  gradual  loss  of  hear- 
ing subsequently — as,  for  instance,  by  some  atrophic  process. 

Mr.  Hinton  was  inclined  to  think  that  in  all  instances  of  loss 
of  hearing,  apparently  from  slight  causes,  it  might  be  found  that 
some  previous  source  of  injury  to  the  ear  had  existed.  He  quotes 
some  cases  to  illustrate  that  view.  He  speaks  of  a  concussion 
sometimes  jarring  the  labyrinth,  not  into  complete  paralysis,  but 
into  a  state  of  extreme  liability  to  this  condition.1 


ANEURISM— TUMORS. 

Aneurism  of  the  basilar  artery,  cerebral  tumors,  and,  in  fact, 
all  varieties  of  intracranial  disease,  may  cause  tinnitus  aurium 
and  impairment  of  hearing  ;  but  all  such  cases  require  special 
study,  and  hardly  demand  a  detailed  notice.  Griesinger  says 
that  the  symptoms  of  disease  of  the  nerve,  or  its  expansion,  aris- 

1  Questions  of  Aural  Surgery,  p.  208. 


676  TUMORS   OF   CEKEBRUM. 

ing  from  aneurism,  are  :  Difficulty  in  swallowing  ;  occasionally 
spasmodic  deglutition  ;  impairment  of  hearing,  or  even  complete 
deafness,  often  appearing  at  intervals,  with  great  tinnitus  ;  dif- 
ficulty of  respiration  and  articulation  ;  interference  with  the  ex- 
cretion of  urine,  without  any  impairment  of  the  intellectual 
functions  ;  and,  finally,  paraplegia.  Von  Troltsch  states  that  a 
constant  sensation  of  knocking  in  the  back  of  the  head  is  also  a 
suspicious  symptom. 

Dr.  Hughlings  Jackson  believes  that  deafness  (excluding 
cases  manifestly  due  to  disease  of  the  apparatus  of  hearing)  is  a 
rare  complication  of  intracranial  disease.  It  is  very  much  less 
common  than  optic  neuritis.  Dr.  Jackson  has  not  yet  seen  an 
autopsy  which  showed  that  deafness  had  depended  upon  adven- 
titious products,  nor  upon  "any  sort  of  disease  of  either  cerebral 
hemisphere."  One  case  '  is  recorded,  however,  which  Dr.  Jack- 
son quotes,  of  tumor  of  the  left  cerebral  hemisphere,  where 
there  has  been  deafness  of  both  ears.  Dr.  Jackson  thinks  that 
deafness  does  not  result  from  intercranial  tumor,  or  other  ad- 
ventitious product,  unless  the  auditory  nerve  is  actually  in- 
volved or  pressed  upon. 

According  to  Schwartze,8  it  has  been  estimated  by  Calmeil 
that  impairment  of  hearing  occurs  in  about  one-ninth  of  all 
cases  of  cerebral  tumors.  Aural  symptoms  occurred,  in  77  cases 
of  tumors  of  the  cerebellum,  7  times  ;  in  26  cases  of  tumors  of 
the  pons,  7  times  ;  in  27  cases  of  tumors"  of  the  middle  lobe,  3 
times  ;  but  not  once  in  27  tumors  of  the  anterior  lobe,  nor  in  14 
cases  of  the  posterior  lobe,  and  4  of  the  fourth  ventricle. 

Deafness  of  one  side,  according  to  Cruveilhier,  quoted  by 
Schwartze,  was  one  of  the  first  symptoms  in  a  number  of  cases 
of  central  tumors.  Schwartze  further  says,  that  impairment  of 
hearing  on  both  sides  not  unfrequently  occurs  in  tumors  of  the 
cerebellum,  and  when  from  the  situation  of  the  tumor  we  know 
that  it  does  not  press  directly  upon  the  nerve-trunk  of  the  oppo- 
site side,  nor  upon  its  origin  in  the  medulla,  and  when  there  are 
no  symptoms  of  paralysis  of  other  cerebral  or  spinal  nerves, 
Schwartze  thinks  that  there  may  be  a  neuritis  or  oedema  in 
these  cases. 

DISEASE   OF  THE  SEMI-CIRCULAR  CANALS. 

In  the  beginning  of  the  preceding  chapter  it  was  said,  that  it 
is  now  possible  to  diagnosticate  disease  of  the  cochlea  and  of  the 
semi-circular  canals,  as  distinguished  from  diseases  of  the  other 

1  Royal  London  Ophthalmic  Hospital  Reports,  vol.  iv.,  part  iv.,  p.  420. 

8  Handbuch  der  pathologischen  Auatomie,  by  E.  Klebs.    Gehororgan,  by  Schwartze. 


DISEASE   OF   SEMI-CIRCULAR   CANALS.  677 

parts  of  the  labyrinth.  I  think  this  has  been  shown  to  be  true 
as  regards  the  cochlea.  As  to  the  diseases  of  the  semi-circular 
canals,  the  late  P.  Meniere,1  of  Paris,  reported  a  case  which  has 
become  classical.  The  deductions  from  it  have  not  always  been 
justified  by  the  facts.  The  term  Meniere's  disease  has  been  used 
so  indiscriminately,  especially  by  neurologists,  that  it  has  con- 
fused our  ideas  as  to  the  significance  of  vertigo,  nausea,  and  ina- 
bility to  walk  without  staggering,  when  they  occur  in  connection 
with  sudden  loss  of  hearing.  In  one  of  Meniere.'s  cases  he  found 
a  kind  of  bloody  exudation  in  the  semi-circular  canals,  while  the 
brain,  the  cerebellum,  and  the  medulla  were  sound.  This  case 
was  that  of  a  young  woman,  who,  while  menstruating,  took  cold 
from  riding  on  the  top  of  a  diligence.  The  other  cases,  nine  in 
number,  are  clinical  accounts  of  cases  of  sudden  deafness,  in 
which  it  is  probable  that  the  semi-circular  canals  were  pressed 
upon  or  diseased,  for  there  was  vertigo  and  a  staggering  gait. 
Some  of  these  cases  were  perhaps  of  tympanic  origin,  certainly 
some  were  cerebral  rather  than  aural,  and  the  pressure  upon  the 
semi-circular  canals  was  not  from  any  exudation  within  them. 
As  has  been  seen  in  the  preceding  pages,  aural  vertigo  is  by  no 
means  always  dependent  upon  disease  of  the  labyrinth. 

Meniere  read  his  first  paper  upon  the  subject  before  the  Acad- 
emy of  Medicine  in  Paris,  January  8,  1861,  and  in  it  he  claimed 
that  the  lesion  causing  the  following  train  of  symptoms,  namely, 
vertigo,  dizziness,  uncertain  gait,  nausea,  followed  by  deafness, 
•was  situated  in  the  semi-circular  canals.  Whether  or  not  cases 
were  all  to  be  referred  to  the  labyrinth  as  their  point  of  origin, 
they  cannot,  with  our  present  knowledge  of  pathology,  certainly 
be  referred  to  the  semi-circular  canals.  There  is  a  vertigo  of 
tympanic  origin,  also  one  proceeding  from  primary  disease  of  the 
labyrinth,  as  well  as  one  from  the  cerebrum.  All  of  these  forms 
may  be  accompanied  by  sudden  deafness.  The  deafness  from 
the  impaction  of  cerumen  is  sudden  in  occurrence,  so  also  that 
from  exudation  or  hemorrhage  into  the  tympanum,  as  well  as 
that  from  hemorrhage  into  the  labyrinth.  These  all  may  be  ac- 
companied by  vertigo.  A  classification,  then,  which  groups 
under  one  head  of  disease,  all  cases  of  vertigo  attended  by  deaf- 
ness, is  crude,  and  should  be  rejected.  Each  case  should  be 
studied  by  itself,  when  it  will  be  possible,  in  many  instances,  by 
a,  careful  study  of  the  principles  that  have  been  laid  down  in 
this  and  similar  works,  to  determine  the  seat  and  nature  of  the 
lesion.  Meniere  did  an  inestimable  service  to  the  profession  in 
directing  attention  to  the  ear  as  the  seat  of  disease,  formerly 

1  Gazette  Medicale  de  Paris,  1861,  pp.  29,  55,  88,  239,  279,  597. 


678  PRESS UKE    UPON    SEMI-CIRCULAR   CANALS. 

supposed  to  be  in  all  cases  situated  either  in  the  brain  or  the 
stomach.  The  profession  must  now  go  further  and  determine 
what  part  of  the  ear  is  affected  in  individual  cases. 

Dr.  Ormerod '  has  called  attention  to  the  fact,  obvious  to  any 
one  who  reads  Meniere's  cases,  that  "the  paroxysms  of  vertigo 
and  vomiting  are  more  sudden,  more  violent,  more  definitely 
paroxysmal "  than  the  vertigo  from  chronic  disease  of  the  middle 
ear,  and  that  what  Hughlings  Jackson  calls  the  "vital  symp- 
toms " — perspiration,  pallor,  and  faintness — are  more  marked. 
Yet,  as  this  writer  admits,  the  vertigo  from  acute  disease  of  the 
middle  ear  may  be  paroxysmal  and  severe,  although  then  the  se- 
verity of  the  symptoms,  taken  in  connection  with  others,  may  be 
of  value  in  making  up  a  diagnosis  as  to  the  seat  of  the  lesion,  it 
cannot  be  said  to  be  a  pathognomonic  guide.  As  before  said  in 
this  work,  I  have  seen  the  most  alarming  vertigo — faintness  ap- 
proaching to  coma — from  syringing  the  ear. 

CASE  I. — Sudden  Deafness — Vertigo — Infantile  Earaches — Syphilis  Years  pre- 
viously.— E.  B.  L ,  aged  fifty-one.  November  26,  1881.  The  patient  state* 

that  as  he  attempted  to  dance  at  a  ball  a  year  and  eight  months  ago,  he  found  he 
could  not  hear  a  sound.  He  rubbed  his  ears  vigorously  and  the  power  of  hear- 
ing returned.  The  next  morning  he  had  vertigo  to  such  an  extent  that  he  could 
not  get  out  of  bed,  could  not  even  hold  up  his  head.  There  was  also  nausea  for 
a  day  or  so.  When  he  finally  got  about  he  staggered  in  his  gait.  He  has  been 
an  overworked  man  for  five  or  six  years.  He  had  syphilis  twenty-one  year* 
ago — chancre,  eruption,  alopoecia,  sore  throat.  H.  D.,  Bight  ear,  *?$£-  ;  left,  -Y\. 
Bone  conduction  is  better  than  aerial  on  the  right  side.  The  aerial  is  the  same 
as  bone  on  the  left.  Hears  worse  in  a  noise.  Bight  membrana  tympani,  poor 
light  spot ;  left,  opaque,  light  spot  only  on  periphery.  His  head  is  now  improv- 
ing. Tinnitus  aurium  is  not  very  troublesome.  When  he  had  vertigo,  the  sensa- 
tions were  of  turning  to  the  right.  No  vertigo  for  the  past  six  or  seven  weeks. 
The  second  examination  showed  that  the  aerial  conduction  was  better  on  each 
side.  There  is  a  history  of  earaches  as  a  child.  The  drum-heads  are  cicatricial. 
He  has  been  subjected  to  thorough  treatment  by  mercury  several  times,  he  says. 
His  ears  feel  better  after  inflation. 

This  was  a  case  of  chronic  disease  of  the  middle  ears,  in 
which  the  labyrinth,  especially  the  semi-circular  canals,  became 
secondarily  affected,  by  pressure,  it  may  be  supposed,  and  not 
from  any  disease  in  them.  To  call  such  a  case  one  of  Meniere's 
disease,  is  not  to  give  any  very  definite  idea  of  its  nature.  The 
history  of  earaches,  the  appearance  of  the  drum-heads,  the  syphi- 
litic disease  of  years  before,  combine  to  give  us  an  accurate  no- 
tion of  the  causes  and  nature  of  the  disease. 

CASE  LT. — Sore  Tliroat — Great  Loss  of  Hearing — Inability  to  Walk  Straight.— 
General  X ,  aged  forty-four.  Seven  years  ago  while  he  had  a  sore  throat, 

1  Brain,  vol.  vi.,  p.  33. 


PRESSUKE   UPON   SEMI-CIRCULAR   CANALS. 

he  found  himself  very  hard  of  hearing,  with  inability  to  walk  straight.  "  He 
could  not  control  his  lower  limbs."  Noise  made  his  hearing  much  worse.  Hear- 
ing distance  :  Eight  ear,  ^  ;  left,  ^$.  Aerial  conduction  better  than  by  bone  on 
left  side.  Both  drum-heads  are  tympanitic.  He  can  now  walk  pretty  well. 

In  this  case  there  may  have  been  a  tympanic  hemorrhage,  such 
as  I  have  seen  in  the  course  of  acute  catarrh,  which  caused  the 
want  of  ability  to  walk — for  I  have  seen  failure  of  power  of  main- 
taining the  equilibrium  from  such  a  cause — or  the  lesion  may 
have  been  in  the  medulla.  That  it  was  of  tympanic  origin  seems 
to  me  more  probable.  The  proper  way  to  describe  cases  of  ver- 
tigo and  inability  to  walk  straight  in  cases  of  aural  disease  is  to 
speak  of  them  as  of  peripheric  (external  auditory  canal),  tym- 
panic, labyrinth  or  cerebral  origin.  It  is  possible  in  many  cases 
to  make  such  an  analysis  of  the  cases  of  pressure  upon,  or  dis- 
ease in,  the  semi-circular  canals.  These  cases  are  not  of  the 
severe  type  of  those  presented  by  Meniere,  but  they  are  such  as 
are  constantly,  as  it  seems  to  me,  improperly  and  insufficiently 
described  by  this  name.  More  serious  cases  of  the  same  charac- 
ter may  be  found  in  other  parts  of  this  boolc. 

EPILEPSY   AND    AURAL   DISEASE. 

The  relation  of  aural  disease  to  epilepsy,  has  been  mentioned 
in  the  discussion  of  foreign  bodies  and  ear  cough,  but  it  cannot 
be  said  that  the  subject  has  yet  been  fairly  studied,  except  from 
the  point  of  the  reflex  origin  of  epilepsy  from  suppuration  of 
the  tympanum,  foreign  bodies  in  the  auditory  canal,  and  so  forth, 
although  I  have  seen  cases  of  epilepsy  apparently  caused  by  such 
diseases,  and  I  have  also  seen  epileptics  who  suffered  from 
chronic  non-suppurative  disease  of  the  middle  ear.  Ormerod 
found  that  of  100  cases  of  undoubted  aural  disease,  as  deter- 
mined by  Dr.  Urban  Pritchard  and  Mr.  Cumberbatch  of  St.  Bar- 
tholomew's Hospital,  "seven  had  had  bona  fide  epileptic  fits." 
This  the  writer  states  is  a  large  proportion,  for  Niemeyer,  as 
he  says,  estimates  that  there  are  only  six  cases  of  epilepsy  to 
every  1,000  persons,  while  Russell  Reynolds  maintains  that  this 
estimate  is  far  too  high.  I  have  no  doubt,  as  suggested  by 
Ormerod,  that  aural  disease  and  disease  situated  not  only  in  the 
peripheric  portions,  but  in  the  labyrinth,  may  excite  epilepsy ; 
but  more  investigation  is  required  upon  this  subject. 

Pathology. — In  passing  over  the  subject  of  the  causes  of  dis- 
ease of  the  internal  ear,  we  have  alluded  to  the  pathology  of  the 
affection  ;  but  it  may  be  well  to  tabulate  the  post-mortem  ap- 
pearances that  have  been  found  in  the  labyrinth.  Inasmuch  as 


680  PATHOLOGY   OF   INTERNAL   EAR. 

very  few  of  these  appearances  have  been  accompanied  by  the 
history  of  the  case,  they  have  not  the  importance  that  they 
would  otherwise  have  had.  Yet  they  may  be  of  service  as  a 
basis  for  future  investigation. 

Absence  of  auditory  nerve 1 

Atrophy  of  auditory  nerve 10 

Suppuration 1 

Tumor  upon 1 

Hemorrhage  upon 2 

Thickened  membranous  labyrinth 11 

Atrophy  of  membranous  labyrinth , 22 

Congestion 1 

Suppuration  of  membranous  labyrinth 3 

Serum  in  labyrinth 3 

Opaque  fluid  in  labyrinth 3 

Black  pigment-cells  too  abundant 5 

Distention  of  blood-vessels  of  cochlea 3 

Fluid,  opaque 4 

Pus  in  cochlea 1 

Thickened  lamina  spiralis 1 

Osseous  wall  of  semi-circular  canals  incomplete 3 

Enlargement  and  congestion  of  blood-vessels  (Hinton  ') 4 

Hypersemia  of  the  various  parts,  or  of  the  whole  contents 
of  the  labyrinth,  has  been  found  in  typhus  and  puerperal  fever, 
in  acute  tuberculosis,  and  in  cases  of  poisoning  by  carbonic 
oxide  gas ;  also  in  meningitis,  and  in  cases  of  disturbances  of 
circulation  from  disease  of  the  heart,  and  in  emphysema  of  the 
lungs.  Hypersemia  of  the  labyrinth  may  result  from  vaso-motor 
disturbances  of  innervation. 

According  to  Erb,8  atrophy  of  the  acoustic  nerve  occasionally 
occurs  in  tabes  dorsalis. 

Tumors — sarcoma,  neuroma,  and  gummata — may  enter  the 
meatus  auditorius  internus. 

Treatment. — In  addition  to  what  has  already  been  said  as  to 
the  treatment  of  disease  of  the  internal  ear,  it  may  be  proper  to 
add,  that  before  any  treatment  is  entered  upon,  the  situation  of 
the  lesion  and  its  cause  should  be  made  out  if  possible.  With- 
out this  all  treatment  will  be  like  working  in  the  dark,  and 
worse  than  useless.  True  inflammation  of  the  membranous 
labyrinth  should  be  treated  by  absolute  quiet  and  rest,  leeches 
to  the  mastoid  and  tragus,  pedeluvia,  and  purgations.  The  use 
of  quinine  and  cold  applications  to  the  head  should  be  avoided, 

1  Questions  of  Aural  Surgery,  p.  255. 
8  Ziemssen's  Handbuch,  p.  142. 


TREATMENT  OF  INTERNAL  EAR.  681 

as  well  as  all  inflations  of  the  tympanum.  Syphilitic  affections 
of  the  labyrinth,  if  treated  at  an  early  stage  and  vigorously,  by 
the  mercury  and  iodide  of  potassium  treatment,  may  recover. 
Traumatic  affections  of  the  labyrinth  are  usually  hopeless  from 
the  start,  as  far  as  restoring  the  hearing  is  concerned  ;  but  much 
can  be  done  by  quiet,  leeches,  counter-irritation  and  the  like  in 
removing  the  symptoms  of  tinnitus,  vertigo,  double  hearing,  and 
so  forth. 

Chronic  affections  of  the  labyrinth  are,  unless  of  a  syphilitic 
origin,  so  far  as  my  experience  goes,  utterly  hopeless.  Elec- 
tricity has  a  much-vaunted  reputation,  among  inexact  observ- 
ers, for  its  cures  of  nerve-deafness  ;  but  there  are  no  authentic 
cases  on  record  of  a  cure  of  a  true  inflammatory  affection 
of  the  labyrinth  by  this  agent.  The  only  seeming  exception 
to  this  rule  is  a  case"  reported  by  Moos,1  which  he  entitles  "  Re- 
covery from  Complete  Nervous  Deafness."  The  constant  cur- 
rent was  used  successfully  in  what  seems  to  me  to  have  been  a 
case  of  impairment  of  hearing  occurring  in  the  course  of  an 
hysterical  affection.  The  patient  had  acute  articular  rheuma- 
tism, and  in  the  fifth  week  hysterical  symptoms  appeared. 
There  was  great  sensitiveness  of  the  ear,  such  as  occurs  in  other 
parts  of  the  body  in  hysterical  women,  and  increased  hearing 
power.  The  patient  lay  for  nine  days  without  moving  on  the 
right  side,  and  thus  an  ulcer  of  the  concha  was  caused.  She 
took  large  doses  of  quinine  for  these  nine  days,  when  impairment 
of  hearing  occurred,  and  continued  to  increase  until  the  patient 
was  communicated  with  in  writing.  In  the  eleventh  week  te- 
tanic spasms  occurred.  The  galvanic  current  was  then  em- 
ployed, twelve  elements  being  used.  The  symptoms,  except 
the  deafness,  soon  subsided,  and  a  thorough  course  of  galvani- 
zation of  the  ears  restored  the  power  of  the  right  one  perfectly, 
and  of  the  left  in  all  respects,  except  the  inability  to  distinguish 
the  highest  note  of  the  seven-octave  piano. 

I  confess  I  do  not  feel  the  enthusiasm  over  this  case  which  is 
exhibited  by  Professor  Moos,  which,  according  to  his  hopes,  is  to 
"  toll  the  knell  for  all  the  opponents  of  the  therapeutic  value  of 
electricity  in  aural  disease."  In  my  opinion  the  loss  of  hearing 
was  caused  by  the  quinine,  and  the  partial  recovery  due  to  the 
fact  that  its  use  was  suspended. 

Beard  and  Rockwell2  give  their  views  as  to  the  value  of  elec- 
tricity in  the  treatment  of  diseases  of  the  auditory  nerve  and 
labyrinth  in  the  following  cautious  language:  "Cases  of  nerv- 

1  Archives  of  Ophthalmology  and  Otology,  Bd.  I.,  No.  2. 

*  A  Practical  Treatise  on  Medical  and  Surgical  Electricity,  pp.  571-72. 


682  TREATMENT  OF  INTERNAL  EAR. 

ous  deafness,  or  of  deafness  resulting  from  various  pathological 
conditions,  with  which  a  morbid  condition  of  the  auditory  nerve 
is  complicated,  and  all  cases  of  tinnitus  aurium,  whatever  may 
be  their  supposed  pathology,  should  only  be  regarded  as  hopeless 
after  the  failure  of  persevering  and  varied  treatment  by  elec- 
tricity, although  perfect  or  approximate  cures  will  be  obtained 
only  in  a  small  percentage  of  the  cases.  The  treatment  of  opac- 
ity and  thickening  of  the  drum,  and  of  chronic  inflammation 
(with  the  consequent  adhesions  and  other  morbid  changes)  of 
the  middle  ear  and  Eustachian  tube,  offers  a  fair  and  important 
field  for  electrical  experiment." 

Dr.  Knapp  says:1  "I  have  tried  it  electricity  in  nearly  all 
reported  cases,  but  without  a  shade  of  improvement." 

Dr.  Sexton  writes  me  that  he  has  experimented  with  electri- 
city in  aural  disease  for  two  years,  both  in  private  and  public 
practice.  He  is  convinced  of  the  correctness  of  Brenner's  for- 
mula ;  but  in  all  his  cases,  Dr.  Sexton  says,  "there  was  no  marked 
improvement  in  the  hearing."  "  In  a  few  cases  of  impaired  hear- 
ing, where  there  were  the  accompanying  symptoms  of  dizziness 
or  nervous  headache,  the  advantages  of  the  treatment  were  de- 
cided." 

My  own  experience  has  been  purely  negative.  I  have  never 
seen  any  improvement,  in  any  forms  of  nerve-deafness,  from 
the  use  of  electricity  in  any  form.  I  fear,  that  we  must  abandon 
the  hopes  entertained  by  some,  of  the  powers  of  this  subtle  agent 
in  those  as  yet  mysterious  diseases,  the  affections  of  the  inter- 
nal ear. 

The  anaemia  of  the  labyrinth  that  sometimes  occurs  after 
typhoid  fever,  and  perhaps  after  other  serious  diseases  of  an  ex- 
haustive character,  may  be  successfully  combated  if  it  be  not 
treated  by  the  usual  means  for  disease  of  the  middle  ear.  In- 
flation, either  by  the  catheter  or  Politzer's  method,  should  be 
avoided.  Counter-irritation  over  the  mastoid,  and  tonics  will 
often  be  of  service  ;  while  quinine,  salycilic  acid,  and  other  agents 
which  excite  tinnitus  aurium  should  be  avoided.  The  patient 
should  be  kept  away  from  noisy  places,  and  avoid  any  exposure 
to  loud  sounds.  It  is  well  to  cause  such  subjects  ;  on  going  into 
the  open  air  during  convalescence,  to  wear  cotton  or  wool  in 
the  external  meatus,  in  order  to  protect  their  ears  from  the 
shock  of  noises. 

1  Archives  of  Ophthalmology  and  Otology,  vol.  ii.,  No.  1. 


DEAF-MUTEISM 


AND 


MECHANICAL  ASSISTANCE  TO  THE  HEARING. 


CHAPTER   XXIII. 

DEAF-MUTEISM— MECHANICAL  ASSISTANCE  TO  THE  HEAEING. 

Acquired  and  Congenital  Cases.  —At  what  Age  are  Children  Conscious  of  Sounds  ? — 
Causes. — Tables  of  Examination  of  147  Cases. — Hearing-trumpets. — Audiphone. 

THERE  is  no  logical  reason  for  the  discussion  of  deaf-muteism 
in  a  treatise  upon  the  diseases  of  the  ear,  as  a  subject  apart  by 
itself,  any  more  than  there  is  for  the  consideration  of  blind- 
ness in  a  work  upon  the  eye.  But  long-established  custom 
among  writers  on  otology  renders  it  proper  that  a  few  pages 
should  be  given  to  this  important  theme  in  this  text-book.  I 
shall,  however,  say  nothing  upon  methods  of  instruction  of  deaf- 
mutes,  but  refer  my  readers  to  the  appropriate  treatises  and  au- 
thorities for  knowledge  on  this  subject. 

Deaf-muteism  is  caused  by  diseases  of  the  middle  and  inter- 
nal ears.  These  diseases  are  of  various  kinds,  and  have  been 
fully  discussed  in  the  preceding  chapters  of  this  work.  The 
only  reason  that  deaf  persons  become  mutes  is  that  the  disease 
of  the  ear  occurs  either  before  birth,  or  so  shortly  after,  that 
its  victim  is  unable  to  learn  to  imitate  speech.  There  are  no 
changes  in  the  larynx  that  prevent  deaf-mutes  from  articulat- 
ing distinctly,  except  those  that  may  possibly  come  from  disuse 
of  the  organ. 

Persons  who  become  completely  deaf  later  in  life,  do  not  lose 
the  power  of  speech  ;  but  they  usually  speak  in  an  unnatural 
tone,  because  they  are  unable  to  hear  their  own  voice  with  dis- 
tinctness. Deaf-mutes  may  be  divided  into  two  great  classes. 

I. — The  acquired  cases,  or  those  in  whom  the  disease  of  the 
ear  has  occurred  after  birth,  from  some  traceable  cause. 

II. — The  congenital  cases. 

It  is  very  difficult  to  come  to  a  correct  conclusion  as  to  the 
relative  frequency  of  congenital  and  acquired  deaf-muteism. 
The  tables  that  are  made  up  by  the  directors  of  schools  for  the 
deaf  and  dumb  are  not  trustworty,  because  they  are  taken  from 
the  statements  of  persons  who  are  seldom  exact  observers — the 
parents  or  friends  of  the  children.  The  late  Dr.  George  M. 


686  DEAF-MUTEISM. 

Beard  and  myself  '  examined  two  hundred  and  ninety-six  cases 
of  deaf -muteism,  with  their  histories,  in  the  schools  of  New  York 
City,  and  Hartford,  Conn.,  and  the  result  of  our  examination 
was,  that  about  sixty-one  per  cent,  of  these  cases  were  probably 
congenital,  and  that  the  remaining  thirty-nine  per  cent,  were 
acquired.  Wilde's  statistics  show  that  about  fifty  per  cent,  are 
of  the  acquired  form.  The  exact  truth  as  to  the  time  when  the 
deafness  occurred  is  something  very  difficult  to  ascertain.  It  is 
not  easy  to  learn,  even  when  great  pains  are  taken  by  persons 
well  competent  to  observe,  whether  a  very  young  infant  hears 
well  or  not,  although  we  may  easily  satisfy  ourselves  whether 
or  not  loud  sounds  are  perceived. 

Children  appear  to  be  conscious  of  sounds  during  the  first 
days  of  their  life,  while  at  the  third  month  they  show  an  appre- 
ciation of  particular  sounds,  such  as  chirping,  whistling,  and  the 
like.  From  the  first  month  to  the  third  is  perhaps  the  earliest 
period  at  which  an  opinion  can  be  formed  as  to  the  hearing  of 
an  infant.  I  find  on  inquiry  among  mothers,  that  their  opin- 
ions vary  excessively  upon  this  point.  Some  affirm  that  they  can 
decide  whether  their  children  have  good  hearing  within  a  few 
days  of  their  birth,  while  others  say  that  a  month  or  two  is  re- 
quired. Infants  seem  to  hear  sounds  conducted  through  solid 
media  almost  immediately  ;  that  is,  within  a  few  days  after  birth, 
while  hearing  of  tones  through  the  air  appears  much  later.  They 
will  very  soon  notice  a  jar,  such  as  a  stamp  on  the  floor,  while 
for  the  human  voice  time  is  needed.  Moreover,  an  inflammation 
of  the  ear,  if  not  of  the  suppurative  variety,  may  run  its  entire 
course  in  a  young  child,  and  never  be  recognized  by  physician 
or  friends  as  a  case  of  aural  disease.  It  is  well  known,  and  the 
fact  has  been  before  alluded  to  in  this  volume,  that  a  suppurative 
inflammation  of  the  middle  ear,  in  an  infant,  is  sometimes  first 
recognized  as  such  when  the  pus  breaks  through  the  membrana 
tympani.  The  fact  that  such  severe  processes  may  go  011  in  the 
ears  of  children,  and  escape  recognition,  renders  it  very  probable 
that  even  Wilde's  proportion,  in  which  he  gives  fifty  per  cent,  as 
the  proper  one  for  acquired  deaf -muteism,  is  too  low  a  one.  I 
am  inclined  to  think  that  there  are  many  more  cases  of  children 
becoming  deaf  after  birth,  than  of  intra-uterine  deafness. 

It  does  not  require  absolute  deafness  in  a  young  child  to  pro- 
duce deaf -muteism.  A  case  of  chronic  aural  catarrh,  that  would 
only  inconvenience  a  grown  person,  will  make  an  infant  so  stupid 
that  it  will  soon  cease  to  attempt  to  imitate  speech.  We  have 
all  grades  of  hearing  power  in  so-called  deaf-mutes.  I  have 


1  American  Journal  of  the  Medical  Sciences,  voL  liiL ,  p.  401. 


DEAF-MUTEISM — CAUSES.  687 

seen  two  or  three  cases  of  children  who  were  being  educated  in 
deaf  and  dumb  asylums,  who  could  hear  words  Spoken  into  their 
ears  in  a  very  loud  tone.  In  one  case  the  parents  found  it  too 
much  trouble — inasmuch  as  no  physician  could  be  found  who 
would  treat  the  suppurating  ear — to  teach  their  child  to  speak. 
He  was  consequently  losing  his  speech,  and  also  having  his  life 
placed  in  peril  by  the  neglect  of  the  ulcers  in  his  ears. 

Some  asylums  for  the  deaf-mutes  in  this  country  are  not  at- 
tended by  physicians  competent  to  examine  and  treat  the  ear. 
Many  of  the  inmates  require  constant  and  special  care  of  their 
ears  ;  especially  is  this  true  of  those  affected  with  suppuration  of 
the  ears,  of  whom  there  are  about  twenty  per  cent,  in  the  asy- 
lums. A  certain  and  valuable  degree  of  hearing  might  be  ob- 
tained in  a  few  of  these  cases  by  intelligent  local  treatment. 

Deaf-mutes  should  be  taught  to  speak  by  imitation  of  the  lips 
of  the  speaker.  The  sign  language  has  been  for  so  many  years 
the  means  for  educating  deaf-mutes  in  this  country,  that  lip 
training  has  not  yet  obtained  its  proper  place  with  us  ;  but  it  is 
fast  winning  it.  The  next  generations  will  exhibit  many  more 
deaf-mutes  who  can  converse  with  any  member  of  society,  and 
who  will  not  be  limited  to  the  comparatively  few  who  know  the 
language  of  signs.  I  know  an  accomplished  young  lady,  entirely 
deaf  from  acute  suppuration  of  the  middle  ears,  with  whom  I 
have  often  conversed,  who  takes  her  full  part  in  the  conversa- 
tion of  a  large  family. 

Causes. — The  causes  of  deaf-muteism  are  very  graphically 
set  down  in  the  reports  of  deaf  and  dumb  asylums,  but  unfortu- 
nately these  assigned  causes  are  usually  incorrect.  Thus,  "colic," 
"a  burn,"  "a  fall,"  "fits,"  "mother  marked,"  '  etc.,  figure  in 
such  tables  as  causes  of  deaf-muteism.  Many  of  the  so-called 
facts  in  such  tables  have  been  derived  from  unscientific  obser- 
vers, who  sometimes  have  very  positive  opinions  as  to  the 
causes  of  disease,  and  who  believe  that  in  a  severe  fright  to  the 
mother,  the  marriage  of  cousins,  etc.,  ample  causes  are  found 
for  deaf-muteism.  The  investigation  of  the  proximate  causes 
of  deaf-muteism  show,  as  has  been  said,  that  their  victims  have 
become  deaf  from'  precisely  the  same  kinds  of  diseases,  and  in 
about  the  same  proportion,  as  obtains  in  impairment  of  hearing 
or  deafness  occurring  at  a  time  of  life  that  prevents  the  subjects 
from  becoming  dumb  as  well  as  deaf.  Of  the  296  cases  exam- 
ined by  Dr.  Beard  and  myself,  in  only  22  cases  was  the  drum- 
head found  to  be  normal,  and  in  200,  or  more  than  two-thirds  of 

1  On  the  Etiology  of  Acquired  Deaf-Muteism,  by  Clarence  J.  Blake.  Reprint  from 
Boston  Medical  and  Surgical  Journal. 


688  -  DEAF-MUTEISM — CAUSES. 

the  whole  number  examined,  there  was  chronic  pharyngitis  or 
tonsillitis.  Of  the  114  acquired  cases,  the  membrana  tympani 
was  perforated  in  29  cases.  Thus,  suppurative  inflammation 
does  not  seem  to  cause  as  large  a  proportion  of  deaf-muteism 
as  is  usually  supposed.  In  some  of  the  cases,  however,  the 
membrana  tympani  had  once  been  perforated  and  had  healed. 
In  Blake's  statistics,1  forty  per  cent,  of  those  examined,  41  in 
number,  were  classed  by  him  as  acquired  cases.  In  12  of  these 
acquired  cases  the  membrana  tympani  was  perforated  or  de- 
stroyed on  one  or  both  sides.  In  13  of  the  17  cases,  the  deafness 
was  traceable  to  the  pharyngitis  of  scarlet  fever  or  measles. 

The  remote  causes,  or  the  causes  that  tend  to  produce  dis- 
ease of  the  ears  in  intra-uterine  or  infantile  life,  form  a  very  in- 
teresting study,  but  we  have  as  yet  no  very  accurate  data  upon 
which  to  discuss  them.  It  is  an  open  question,  perhaps,  whether 
intermarriage  tends  to  produce  disease  of  the  ear  in  young  sub- 
jects or  not,  whether  it  tends  to  lead  to  arrested  development  in 
young  children  ;  for  there  is  no  doubt  that  some  cases  of  con- 
genital deafness  depend  upon  want  of  proper  development  of 
the  auditory  nerve  and  labyrinth.  I  was  informed  at  Hartford, 
that  a  certain  part  of  our  country,  which  is  somewhat  isolated 
from  the  other  parts  of  the  Union,  and  where  intermarriages 
are  the  rule,  furnished  a  proportionately  large  contingent  of 
cases  of  congenital  deaf-muteism.  The  cases  from  this  district 
that  I  saw  were  in  persons  somewhat  deficient  in  intellect,  and 
we  may  consider  their  etiology  as  identical  with  that  of  idiocy, 
feeble  brains,  or  partial  development  of  other  parts  of  the  body, 
such,  for  example,  as  spina  bifidis,  coloboma  iridis,  etc.  It  is  not 
probable  that  deaf-mute  parents  are  likely  to  beget  children  who 
do  not  hear,  for  the  simple  reason  that  in  the  large  proportion  of 
cases,  the  deafness  depends  upon  inflammatory  action,  which  is 
not  transmitted,  except  possibly  as  a  tendency  or  by  anatomical 
conditions.  Deafness  dependent  upon  imperfect  development  of 
the  ear  or  brain  may  be  inherited. 

Voltolini's  inflammation  of  the  membranous  labyrinth  is 
probably  one  of  the  proximate  causes  of  acquired  deaf-muteism. 
Von  Troltsch  showed  that  a  purulent  process  is  a  very  common 
appearance  in  the  tympanic  cavities  of  half-starved  foundlings. 
I  suppose  that  the  mal-nutrition  of  parents  may  be  traced  as  re- 
mote causes  for  such  affections  of  the  middle  ear. 

We  may  sum  up  the  causes  of  deaf-muteism,  as  developed  in 
clinical  histories  and  in  examinations  on  the  dead  subject,  as 
follows  : 

1  Reprint  from  Boston  Medical  and  Surgical  Journal. 


DEAF-MUTEISM — CAUSES.  689 

1.  Inflammation  of  the  middle  ear,  resulting  in  suppuration, 
or  adhesions,  anchylosis  of  the  ossicula  auditus,  and  so  forth. 

2.  Inflammation  of  the  nerve  or  labyrinth,  resulting  in  sup- 
puration or  thickening  of  the  membranous  labyrinth,  deposits 
in  it,  and  so  forth. 

3.  Arrested  development,  or  absence  of  some  parts  of  the  es- 
sential part  of  the  auditory  apparatus. 

These  are  the  causes  which  are  shown  in  the  table  given  by 
Moos,1  in  his  account  collected  from  various  authorities,  of  sec- 
tions of  the  ears  of  sixty  deaf-mutes,  and  they  agree  well  with 
the  clinical  examinations  and  histories. 

Treatment. — There  is  certainly  no  peculiar  treatment  neces- 
sary for  the  deafness  of  young  children,  which  renders  them 
mute,  because  they  cannot  learn  to  imitate  speech  ;  but  I  cannot 
refrain  from  alluding  to  the  lingering  remains  of  the  barbarism 
of  the  past  centuries,  which  neglects  the  care  of  the  ulcerated 
membrana  tympani,  and  the  swollen  throats  of  the  poor  mutes 
who  suffer  from  chronic  suppuration  and  catarrh  of  the  middle 
ear.  Although  the  educational  wants  of  deaf-mutes  are  now 
well  attended  to,  their  medical  treatment  is  sadly  neglected  in 
the  asylums  and  schools  of  our  country,  as  well  as  at  their  homes. 
It  was  not  until  the  seventh  century  that  the  deaf-mutes  were 
thought  worthy  of  an  education.  The  twentieth  century  will 
probably  arrive  before  every  school  or  asylum  for  these  unfortu- 
nates has  in  attendance  a  physician  who  knows  how  to  examine 
and  treat  a  diseased  ear.  These  schools  are  not  hospitals,  it  is 
true  ;  but  there  is  always  in  them  quite  a  large  proportion  of 
young  patients  who  still  suffer  from  a  disease  which,  although 
it  has  fully  destroyed  the  hearing,  is  not  yet  stayed,  and  which 
often  goes  on  to  destroy  life.  I  refer,  of  course,  more  particu- 
lary  to  the  suppurative  forms  of  disease. 

According  to  the  census  of  1880,  there  were  in  the  United 
States  33,878  deaf-mutes.  Of  these  we  may  believe  that  fifty  per 
cent,  belong  to  the  acquired  cases.  How  many  of  these  belong 
to  what  may  fairly  be  called  preventable  diseases,  it  would  not 
be  possible  to  say  ;  but  certain  it  is,  that  if  diseases  of  the  ear 
had  always  rejoiced  in  the  same  attentive  treatment  as  many  of 
the  less  essential  parts  of  the  body  have  received,  the  number  of 
these  unfortunate  mutes  would  have  been  greatly  lessened. 

The  following  table  shows  the  results  of  an  examination  of 
the  hearing  power  and  membranae  tympani  of  147  deaf-mutes, 
with  a  statement  of  the  causes  assigned  for  their  loss  of  hearing.2 

1  Klinik  der  Ohrenkranklieiten,  p.  341. 
s  Archives  of  Otology,  vol.  xiii. ,  No.  1,  March,  1884. 
44 


690 


EXAMINATION   OF   DEAF-MUTES. 


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EXAMINATION   OF   DEAF-MUTES. 


Remarks. 

Is  very  anaemic. 

Four  out  of  six  brothers 
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The  mother  and  father 
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EXAMINATION   OF   DEAF-MUTES. 


693 


No  perception  of  tuning- 
fork  on  hand. 

a 

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695 


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706  STATISTICS   OF   DEAF-MUTEISM. 

The  following  table  shows  the  statistics  of  deaf-mutes  in  this 
country  in  1880 : 

Total 33,878 

Males 18,567 

Females 15,311 

Native 30,507 

Foreign 3,371 

White 30,661 

Colored 3,217 

Total  population  of  the  United  States  : 

Native 43,475,840 

Foreign 6,679,943 


i  50,155,783 

In  the  year  1867,  in  conjunction  with  the  late  Dr.  George  M. 
Beard,  I  examined  296  deaf-mutes  with  a  view  of  contributing 
something  to  our  knowledge  of  the  causes  x>f  deaf-muteism.  The 
results  of  these  examinations  were  meagre,  and  they  were  made 
to  appear  even  less  complete  than  they  were  in  reality,  because 
the  editor  of  the  journal  in  which  they  were  published  '  could 
not  give  us  the  space  to  publish  the  tables  upon  which  our  con- 
clusions were  founded,  and  because  the  tables  were,  lost  so  that 
they  could  not  be  published  elsewhere.  Since  the  use  of  the 
tuning-fork  has  come  to  play  such  an  important  part  in  aural 
diagnosis,  it  has  been  made  available  also  in  the  examination  of 
deaf-mutes.  De  Rossi,2  of  Rome,  has  made  the  most  complete 
examinations  of  which  I  know,  as  to  the  hearing  power  of  deaf- 
mutes.  He  examined  seventy  individuals  with  the  speaking- 
tube  and  tuning-fork.  Twenty- seven  heard  the  voice,  four  the 
watch,  thirty-nine  the  tuning-fork  vibrating  in  the  air.  Nearly 
all  of  the  seventy  perceived  the  vibrations  through  the  bones, 
eleven  only  had  no  perception  by  bone-conduction,  and  De  Rossi 
found  only  three  cases  of  what  he  termed  total  deafness.  These 
examinations  of  De  Rossi  seem  to  me  to  furnish  more  reliable 
data  than  the  cases  of  Toynbee  and  Kramer,  and  chiefly  because 
the  examination  by  the  tuning-fork  and  speaking-tube  was  not 
made  by  them.  Accordingly,  I  have  imitated  the  examinations 
of  De  Rossi  in  those  I  have  made.  The  imitation  was  an  uncon- 
scious one,  however,  for  it  was  not  until  I  had  nearly  finished 
my  examinations,  that  I  found  from  a  scanty  reference  in  Hart- 

1  American  Journal  of  the  Medical  Sciences,  vol.  liii.,  p.  399. 

2  Relazione  sopra  1'  Ospizio   del  Sordi-Muti  de   Roma.      Quoted   by   Hartrnann. 
"Deaf-Mutism."     Translation,  p.  84. 


CAUSES   OF   DEAF-MUTEISM.  707 

tnann's  book  on  deaf -muteism,  that  De  Rossi  had  preceded  me  in 
these  tests. 

The  tuning-fork  seems  to  me  a  very  important  means  of  de- 
termining the  seat  of  the  lesion,  in  cases  of  impairment  of  the 
hearing  in  which  muteism  does  not  result.  I  was  desirous  to 
know  what  it  would  indicate  in  those  who  are  dumb  as  well  as 
deaf.  I  found  in  the  institution  for  the  improved  instruction  of 
deaf-mutes  in  this  city,  the  most  ample  opportunities  for  exam- 
inations. Every  facility  was  afforded  me  by  the  principal,  Mr. 
Greenberger,  and  I  desire  to  thank  him  not  only  for  the  advan- 
tages he  so  liberally  afforded  me,  but  also  for  his  valuable  assist- 
ance given  in  a  truly  scientific  spirit.  I  was  also  assisted  by 
Dr.  J.  B.  Emerson  and  Dr.  George  J.  Bull,  without  whose  aid  I 
should  not  have  been  able  to  accomplish  the  work  of  examining 
so  many  pupils.  I  used  a  "  C  * "  tuning-fork  in  the  examination 
as  to  the  aerial  and  bone-conduction.  The  tests  by  speaking- 
tube  were  made  by  Mr.  Greenberger,  and  I  have  relied  wholly 
upon  his  statements  as  to  that  point. 

TABLE  I. — One  Hundred  and  Forty-seven  Cases  of  Deaf -Muteism  (causes  stated  by 

parent  or  guardian). 

No.  No. 

Born  deaf 44  Whooping-cough 2 

Cerebro-spinal  meningitis 27  Spinal  trouble 1 

Scarlet  fever 16  Mumps 2 

Brain  fever ...  13  Pneumonia 2 

Meningitis 4  Gastric  fever 1 

Measles 7  Cholera  iufantum 1 

Fall  on  head 7  Intermittent  fever 1 

Unknown 7  Syphilis '. 1 

Convulsions 4  Varioloid 1 

Hydrocephalus 3 

Fever 3                                                                  147 

In  regard  to  this  table,  I  can  only  say  that  it  is  as  reliable  as 
any  that  it  seems  possibl  to  get  from  any  institution.  As  far 
as  the  statements  as  to  scarlet  fever,  measles,  cerebro-spinal 
meningitis,  meningitis,  mumps,  and  syphilis  go,  I  think  it  may 
be  considered  trustworthy.  When  we  enter  the  domain  of  con- 
genital deafness,  or  such  causes  as  "spinal  trouble,"  "fall  on 
head,"  "convulsions,"  there  is  great  uncertainty  as  to  the  actual 
cause.  Yet  these  causes  are  taken  from  blanks  carefully  filled 
out  by  the  parents  or  guardians,  many  of  them  very  intelligent 
people  of  the  higher  walks  of  life,  who  send  their  children  to  be 
under  Mr.  Greenberger's  care.  The  causes  are  more  accurately 


708  CAUSES  OF  DEAF-MUTEISM. 

given,  than  in  the  other  institutions  in  which  I  have  made  ex- 
aminations. It  will  be  seen  there  were  only  fifty-one  cases,  add- 
ing together  the  congenital  and  "unknown,"  or  a  little  more 
than  thirty  per  cent.,  which  may,  with  much  probability,  be  con- 
sidered congenital  cases.  In  our  tables  of  1867,  we  classified 
sixty -one  per  cent,  as  congenital  cases.  Hartmann's  tables1 
show  that  of  8404  deaf-mutes  5546,  or  more  than  sixty-five  per 
cent.,  were  considered  as  congenital  cases.  His  statistics  are 
apparently  made  up  largely  of  official  and  not  personal  examina- 
tions ;  for  in  the  examinations  made  in  Berlin  by  Hartmann  him- 
self, one  hundred  and  eighty-five  in  number,  only  forty-five  are 
classified  as  congenital  cases ;  and  those  made  by  Cohn,  in  Bres- 
lau,  show  about  the  same  proportion — that  is,  of  one  hundred 
and  thirty  deaf-mutes,  fifty-seven  are  said  to  have  been  born 
deaf,  while  in  other  parts  of  Germany,  and  in  Ireland,  the  pro- 
portion of  congenital  cases  is  much  larger.  I  regard  the  official 
tables  of  all  countries  as  valueless,  except  as  to  the  total  number 
of  deaf-mutes.  Those  who  collect  them,  are  usually  entirely 
incompetent  for  the  sifting  of  evidence  necessary  to  get  even 
approximate  truth  upon  this  point. 

TABLE  IL — Results  of  the  Examination  with  the  Tuning-fork  C"  of  One  Hundred 
and  Forty-seven  Deaf -Mutes. 

There  was  no  aerial  conduction  on  either  side,  while  bone  con- 
duction existed  in  . . . .' 74 

Bone  conduction  on  one  side,  both  bone  and  aerial  on  the 

other,  in 1 

No  bone  or  aerial  conduction  on  one  side,  bone  conduction  on 

the  other 10 

Bone  and  aerial  conduction,  both  sides 7 

Bone  and  aerial  conduction  on  one  side,  bone  on  the  other  ....   13 

Neither  bone  nor  aerial  conduction  on  either  side 12 

No  bone  or  aerial  conduction  on  one  side,  both  bone  and  aerial 
on  the  other 1 

118 

In  twenty-nine  cases  the  subjects  were  too  young  or  were 
otherwise  incapacitated  for  intelligent  answers  :  hence  no  con- 
clusions could  be  formed,  except  that  the  large  majority  of 
them  probably  heard  the  tuning-fork  by  bone  conduction. 

I  will  now  present  a  series  of  tables  made  in  consonance  with 
the  supposed  cause  of  the  deafness. 

1  Loc.  cit. ,  p.  64. 


CAUSES   OF  DEAF-MUTEISM.  709 


TABLE  in. — Scarlet  Fever  being  Cause  of  Deafness,  Condition  of  Membrana  Tym- 

pani  (16  cases,  32  ears). 

Absent 1 

Opaque  and  cicatricial 4 

Sunken,  opaque,  small  or  no  light  spot 11 

Perforate  and  ulcerating  9 

Congested 2 

If eoplastic  and  perforate 1 

Neoplastic 2 

Not  well  seen 1 

Perforate,  no  discharge 1 

32 

Tuning-ForTc  Test. 

No  aerial  conduction  but  bone  conduction 17 

Bone  and  aerial  conduction 3 

No  bone  or  aerial  conduction 8 

Unreliable 4 

32 

Age  of  patients  at  time  of  becoming  deaf : 

From  2  to  3  years 2 

3  "  4    "     8 

4  "5    "     3 

5  "6     " 1 

6  "7     "     ..    1 

8  "9     "     1 

16 

There  is  in  these  scarlet  fever  cases  a  large  proportion — 8,  or 
•one  in  4 — where  disease  of  the  nerve  certainly  existed.  It  will 
also  be  remarked  that  there  is  a  large  proportion  of  cases  of 
ulcerative  disease.  That  an  ulcerative  disease  of  the  tympanum 
may  more  readily  involve  the  internal  ear  than  a  plastic  or  catar- 
rhal  inflammation,  is  probably  true.  Yet  the  starting-point  of 
otitis  in  scarlet  fever  is  usually  the  middle  ear. 

TABLE  IV. — Measles  Cause  of  Deafness,  Condition  of  Membrana  Tympani  (1  cases, 

14  ears). 

Sunken,  no  light  spot,  opaque 5 

Congested  ....    1 

Sunken  light  spot 1 

Not  well  seen , 5 

Opaque,  but  good  light  spot 2 

14 


710  CAUSES  OF  DEAF-MUTEISM. 

Tuning-Fork  Test. 

Bone  conduction  but  no  aerial  conduction 6 

Bone  and  aerial  conduction 1 

No  bone  or  aerial  conduction 1 

Unreliable 6 

14 

It  will  be  noted  that  only  one  case  occurs  here  of  those  of 
whom  a  reliable  test  could  be  made,  in  which  it  is  possible  that 
disease  of  the  nerve  alone  exists — that  is,  the  case  in  which  there 
was  neither  bone  nor  aerial  conduction. 

Age  at  which  deafness  occurred  : 

Under  1  year 3 

From  1  to  2  years 3 

"    2  "  3     "    1 

7 

TABLE  V. — Cerebro- Spinal  Meningitis  Cause  of  Deafness,  Condition  of  Membranes 
Tympani  (27  coses,  54  eari). 

Cicatricial 6 

Opaque  6 

Sunken,  fair  light  spot 10 

"        good  color 8 

"       small  or  no  light  spot 16 

Not  well  seen ^  3 

Opaque,  good  light  spot 1 

Cicatricial  and  perforate 2 

Congested  and  sunken 1 

Congested 1 

54 

Tuning-Fork  Test. 

Bone  conduction  only,  no  aerial  conduction 34 

Bone  and  aerial  conduction 5 

Neither  bone  nor  aerial  conduction 8 

47 
Unreliable 7 

Here  the  proportion  of  cases  in  which  it  may  be  conjectured: 
that  the  nerve  alone  is  involved,  was  not  as  large  even  as  in 
scarlet  fever.  There  were  only  eight  ears  of  a  total  of  fifty- 
four,  or  about  one  in  seven.  It  is  in  this  disease,  that  an  affec- 
tion of  the  nerve  has  been  often  assumed  to  be  the  most  frequent 
cause  of  the  deafness. 


CAUSES   OF   DEAF-MUTEISM.  711 

My  clinical  experience  has  been  against  this  view,  and  I 
believe  that  the  few  post-mortem  examinations  that  have  been 
made  of  persons  with  aural  disease  in  cerebro-spinal  meningitis, 
go  to  support  the  view  of  that  experience,  which  is  that  a  lesion 
beginning  in  the  middle  ear,  is  in  a  large  percentage  of  cases  the 
cause  of  the  deafness. 

TABLE  VI. — Deaf  ness  said  to  be  Congenital,  Condition  of  Membrana  Tympani  (44 

cases,  88  ears). 

Normal  color  and  light  spot , ,. ..  II 

Sunken,  opaque,  or  no  light  spot 34 

Obscured  by  wax 10 

Opaque,  large  light  spot 1 

Sunken,  opaque,  but  good  light  spot 14 

Congested,  sunken,  and  small  light  spot 5 

Obscured  by  narrow  canal 6 

Cicatricial  and  perforate 3 

Opaque,  calcareous 1 

88 
Tuning-Fork  Test. 

Bone  conduction,  but  no  aerial 48 

Bone  and  aerial •. 8 

Neither  aerial  nor  bone  14 

Unreliable 18 

88 

Here  the  proportion  of  cases  of  apparent  nerve  or  central 
disease  is  quite  high — fourteen  to  forty-eight,,  or  a  little  more, 
than  one  to  three, 

TABLE  VII.—''  Brain  fever,"  "  Inflammation  of  Brain,*'  "Meningitis*  and  "  Con- 
gestion of  Brain"  said  to  be  the  Cause  of  Deafness,  Condition  of  Membrana 
Tympani  (15  coses,  30  ears}. 

Sunken,  opaque,  small,  or  no,  or  double  light  spot 12 

Normal \ 

Sunken,  good  color,  good  light  spot 7 

Cicatricial 4. 

Not  well  seen 3 

Perforate  and  ulcerating 3 

30 
Tuning-Fork  Test. 

Bone  conduction  only i§ 

Aerial  and  bone 4. 

Uncertain g 

30 


712  CAUSES   OF  DEAF-MUTEISM. 

Age  of  patients  when  deafness  occurred : 

Less  than  1  year 2 

From  1  to  2  years 5 

'     2  "3     ' 1 

'     4"5     '     2 

'     5  "6    «     1 

«      6"7     '     3 

'     8  "9     '     1 

15 

TABLE  Vlil. — Fall  on  Head  Cause  of  Deafness,  Condition  of  Membrana  Tympani 

(7  coses,  14  ears). 

Not  well  seen 5 

Sunken,  opaque,  fair  or  good  light  spot 2 

Sunken,  no  light  spot 2 

Good  light  spot  but  sunken 2 

Sunken,  congested 1 

Good  light  spot 1 

Small     "      "     1 

14 

Tuning-Fork  Test. 

Bone  conduction  only 8 

Neither  bone  nor  aerial 1 

Bone  and  aerial  conduction 1 

Unreliable 4 

•  14 
TABLE  ESL — Cause  Unknown  (7  coses,  14  ears). 

Opaque,  sunken,  good  light  spot 4 

Not  well  seen 1 

Opaque 1 

Good  color,  fair  light  spot 1 

Small  light  spot 1 

Opaque  and  sunken  2 

Sunken,  small  light  spot 2 

"        good  light  spot 1 

Opaque,  good  light  spot 1 

14 

Tuning-Fbrk  Test. 

Bone  conduction  only 10 

Uncertain 4 

14 


CAUSES   OF   DEAF-MUTEISM.  713 

TABLE  X. — Convulsions    Cause  of  Deafness,    Condition  of  Membrana  Tympani 

(4  cases,  8  ears). 

Opaque,  small  light  spot,  good  color 2 

"  sunken,  good  light  spot 2 

Opaque 2 

"  small  light  spot 2 

8 
Tuning-Fork  Test. 

Bone  conduction  only 5 

Aerial  and  bone  conduction 3 

8 
Age  at  which  deafness  occurred  : 

Less  than  1  year 1 

From  1  to  2  years 3 


TABLE  XI. — Syphilis   Cause  of  Deafness,    Condition  of  Membrana   Tympani  (1 

case,  2  ears). 

Bight  much  sunken,  no  light  spot ;  left  slightly  sunken,  medium-sized  light 
spot. 

Tuning-ForJc  Test. 
Kight,  no  aerial  conduction,  but  bone  conduction ;  left,  same. 

In  this  case,  the  only  one  found,  there  was  a  syphilitic  his- 
tory ;  notched  teeth ;  the  subject  has  had  interstitial  keratitis. 
The  disease  seems  to  be  confined  to  the  middle  ear. 

TABLE  TCTt. — Hydrocepfialus  Cause  of  Deafness,  Condition  of  Membrana  Tympani 

(3  coses,  6  ears). 

Not  well  seen 1 

Sunken,  perhaps  perforate 1 

"        small  light  spot .   2 

Opaque,  no  light  spot 2 


Tuning-Fork  Test. 

Bone  conduction  only 6 

Age: 

Less  than  1  year 1 

From  1  to  2  years 1 

Unknown * . .  1 

3 


714  CAUSES  OF  DEAF-MUTEISM, 

TABLE  XIII.  —  Spinal  Meningitis  Cause  of  Deafness,  Condition  of  Membrana  Tym* 

pani  (3  coses,  6  ears). 

Not  well  seen  ............................    ................  2 

Sunken,  opaque,  good  light  spot  .............  .....  .  ..........  1 

Opaque  and  cicatricial  .....................................  1 

Sunken,  no  light  spot  ......................................  2 

6 
Tuning-Fork  Test. 

Bone  conduction  only  ......................................  6 

Age: 

From  2  to  3  years  .........................................  1 

"     5  "6      "     .........................................  1 

"  6  "  7  "  .........................................  1 

3 

TABLE  XIV.  —  Varioloid  Cause  of  Deafness,  Condition  of  Membrana  Tympanr 

(1  case,  2  ears). 

Not  well  seen  .............................................     1 

Good  color,  good  light  spot,  sunken  .........................     1 

2 

Tuning-Fork  Test. 

Aerial  and  bone  conduction  .  ................................     1 

Bone  conduction  only  .....................................     1 

2 

Age  at  which  deafness  occurred  :  one  year  and  four  months. 

TABLE  XV.  —  Pneumonia  Cause  of  Deafness,  Condition  of  Membrana  Tympani: 

(2  cases,  4  ears). 

Sunken,  small  light  spot  ...................................     1 

Not  well  seen  ............................................     1 

Opaque,  sunken,  no  light  spot  ..............................     2 


Tuning-Fork  Test. 

Bone  conduction  only  .....................................    2 

Uncertain  ................................................     2. 

4 
Age: 

Less  than  1  year  ..........................................     1 

From  1  to  2  years  .........................................     1 

2 


CAUSES   OF   DEAF  MUTEISM.  715 

TABLE  XVI. —  Whooping- Cough  Cause  of  Deafness,  Condition  of  Membrana  Tym- 

pani  (2  coses,  4  ears). 

Good  light  spot,  sunken,  opaque 1 

Opaque,  small  light  spot 1 

Sunken,  good  color  1 

Sunken  and  congested 1 

4 
Tuning-Fork  Test. 

Uncertain 1 

Both  aerial  and  bone  conduction 1 

2 
Age: 

"  In  infancy  " 1 

Whooping-cough,  intermittent  fever  at  two  years  and  nine 
months . .  1 


TABLE  XVEL — Cholera  Infantum  Cause  of  Deafness,  Condition  of  Membrana  Tym~ 

pani  (1  case,  2  ears). 
Sunken,  no  light  spot 11 

Tuning-Fork  Test. 

Bone  conduction  only 2 

Age  one  year. 

TABLE  XVill. — Gastric  Fever  Cause  of  Deafness,  Condition  of  Membrana  Tympani 

(1  case,  2  ears). 

Sunken,  opaque,  small  light  spot 1 

Sunken,  good  color,  small  light  spot 1 


Tuning-Fork  Test. 

Bone  conduction  only,  and  that  feeble 2 

Diseases  at  two  years  and  eight  months. 

TABLE  XIX. — Intermittent  Fever  Cause  of  Deafness,  Condition  of  Membrana  Tym- 
pani (1  case,  2  ears). 
Small  light  spot 2 

Tuning-Fork  Test. 
Bone  conduction  only 2 

Intermittent  fever  and  spasms  at  two  years. 


716  CAUSES   OF   DEAF-MUTEISM. 

TABLE  XX. — Mumps  Cause  of  Deafness,   Condition  of  Membrama  Tympani  (2 

coses,  4  ears). 

Bight  opaque,  small  light  spot ;  left  fair  light  spot,  good  color, 

sunken 2 

Bight  and  left  cicatricial 2 

4 

Tuning-Fork  Test,  Unreliable. 
Age: 

A  few  months  old •  1 

Six  years 1 

2 

TABLE  XXI. — Fever  Cause  of  Deafness,  Condition  of  Membrana  Tympani  (3  coses, 

6  ears). 

Sunken,  two  light  spots 2 

Sunken,  small  light  spot    2 

Opaque,  small     "       "     1 

Cicatricial 1 

6 

Tuning-Fork  Test. 

Both  aerial  and  bone  conduction 2 

Bone  conduction  only 4 

6 
Age: 

Nine  months 1 

Five  years 2 

3 

TABLE  XXII. — Coses  in  which  Words  or  Letters  could  be  Heard  through  a  Speaking- 
tube  placed  in  the  Ear  ;  l  Condition  of  Membrana  Tympani  (16  coses,  32  ears). 

Opaque 6 

Sunken 15 

Good  color 4 

Good  light  spots 8 

Small    "      « 6 

INo         "      "    6 

Two  light  spots 1 

Cicatricial 5 

Calcareous 1 

Vascular 1 

Perforated 2 

Not  well  seen  . .  3 


CAUSES   OF   DEAF-MUTEISM.  717 

Tuning-Fork  Test. 

Both  aerial  and  bone  conduction 4 

Bone  only 2 

Bone  both  sides,  aerial  on  one  side 3 

Bone  and  aerial  on  one  side,  neither  on  the  other 1 

Neither  bone  nor  aerial  on  either  side 2 

Unreliable 4 

16 

Disease  Causing  Deafness. 

Born  deaf ^ 5 

Measles 4 

Cerebro-spinal  meningitis 3 

Brain  fever 1 

Convulsions , 1 

Scarlet  fever 1 

•       Unknown  ...    1 

16 

To  this  last  table,  the  words  of  Mr.  Greenberger  should  be 
added  : 

"  Th,e  speaking-tube  is  used  in  these  cases  to  assist  the  schol- 
ars to  speak  better  after  they  have  learned  to  pronounce  them 
from  the  lips.  There  is  not  a  pupil  in  the  school  who  could  be 
taught  to  speak  a  word  from  hearing  it  through  the  tube  alone, 
but  they  will  recognize  words  with  which  they  have  become  fa- 
miliar through  lip-reading." 

A  study  of  these  tables,  especially  with  reference  to  the  con- 
duction of  sounds  to  the  ears  or  auditory  centres  through  bone, 
indicates  to  me  that  a  large  percentage  of  these  deaf-mutes  lost 
their  hearing  from  disease  of  the  middle  ear,  and  that  the  acous- 
tic nerve  was  still  capable  of  appreciating  sound.  It  will  be 
observed  that  in  the  column  of  the  table  in  which  the  answer 
as  to  the  perception  of  the  sound  of  the  tuning-fork  through 
bone  is  given,  it  is  stated  in  many  instances  that  the  subject  of 
examination  states  that  he  or  she  "feels"  it.  I  have  endeav- 
ored to  make  the  tables  a  mirror  of  what  actually  occurred  in 
the  examinations.  It  may  be  stated  that  to  feel  the  vibrations 
of  the  tuning-fork  is  not  to  hear  them,  but  I  am  inclined  to  think 
that  in  most  instances,  if  not  all,  this  perception  is  actually  a 
perception  of  sound.  A  little  thought  as  to  what  sound  is  will, 
I  think,  substantiate  this  view.  We  found,  as  will  be  seen,  a 
small  contingent  who  did  not  respond  in  any  way  to  the  vibra- 
tions of  the  fork.  In  this  small  contingent  the  functions  of 


718  CAUSES   OF   DEAF-MUTEISM. 

the  nerve  were  probably  destroyed.  It  is  natural  to  suppose 
that  about  the  same  proportion  of  infants  and  very  young  chil- 
dren would  suffer  a  lesion  of  the  middle  rather  than  the  internal 
ear,  in  case  the  organ  is  attacked  by  disease,  as  would  be  the 
case  in  adults,  and  this  seems  to  be  indicated  by  these  tables. 

The  deaf-mutes  from  whom  these  tables  are  made  up,  are, 
so  to  speak,  selected  cases,  for  all  or  nearly  all  of  them  have 
good  intellects  and  are  capable  of  being  taught.  There  do  not 
appear  among  them,  therefore,  any  cases  in  which  there  is  a 
lack  of  ordinary  cerebral  development.  In  classifying  unse- 
lected  deaf-mutes,  or-  those  taken  from  the  whole  number  to  be 
found  in  a  district  or  county,  the  number  of  those  deaf  from 
disease  of  the  central  apparatus  would,  of  course,  be  increased. 

It  is  interesting  to  notice  that  a  larger  number  of  the  cases 
are  attributed  to  cerebro  -  spinal  meningitis  than  to  any  one 
cause.  There  were  27  cases  of  this  kind  to  16  of  scarlet  fever. 
"  Brain  fever "  or  meningitis  plays  an  important  part,  in  tlie 
etiology,  for  there  were  17  cases  among  the  total  number  of  147. 
I  cannot  but  hope  that  the  careful  instruction  of  the  public  and 
the  profession,  as  to  the  necessity  for  the  treatment  of  suppura- 
tion of  the  ear,  has  borne  fruit,  in  the  prevention  of  many  cases 
of  destruction  of  the  ears  by  the  means  used  to  stop  the  inflam- 
mation. In  the  examinations  made  by  Dr.  Beard  and  myself 
some  eighteen  years  ago,  there  was  a  larger  percentage  of  cases 
caused  by  scarlet  fever  and  producing  suppuration  in  the  middle 
ear.  We  seem  as  yet  without  means  of  successfully  treating  an 
inflammation  of  the  ear,  when  it  occurs  in  the  course  of  cerebro- 
spinal  meningitis.  If  there  be  an  inflammation  of  the  mem- 
branous labyrinth,  which  is  mistaken  for  this  disease,  it  is  as 
yet  not  at  all  recognized  by  the  profession  at  large. 

The  observations  of  Mr.  Lawson  Tait '  upon  the  congenital  deafness  of  white 
cats  have  an  interesting  bearing  upon  the  situation  of  the  lesion  in  deaf-mutes. 
Mr.  Tait  says  of  a  cat  that  lived  in  his  house  for  eleven  .years,  that  he  was  deaf 
to  impressions  conveyed  through  the  air,  "but  his  intelligence  could  be  reached 
by  impressions  conveyed  through  solid  media."  When  he  was  wanted,  he  would 
respond  to  a  peculiar  stamp  on  the  floor.  After  this  interesting  statement,  Mr. 
Tait  passes,  as  it  seems  to  me,  out  of  the  region  of  facts,  to  state  that  "  human 
deaf-mutes  are  those  in  whom  deafness  is  cochlea r  as  well  as  tympanic."  From 
this  premise  he  concludes  that  cats  are  not  mutes  because  their  deafness  has  a 
tympanic  origin.  But  human  mutes  emit  sounds  of  various  kinds  as  well  as 
animals  who  are  deaf.  The  origin  of  the  muteness  is  to  be  found  in  the 
non-ability  of  hearing,  and  not  in  the  situation  of  the  lesion  that  causes  the 
deafness.  The  post-mortem  investigation  of  Mr.  Tait's  cat  was  most  interest- 
ing. It  was  made  by  Drs.  Cumberbatch  and  Dr.  Gibbs.  All  tlie  structures  in  the 


1  Nature,  December  13,  1883,  and  January  10,  1884. 


CONGENITAL   DEAFNESS   OF   CATS. 


719 


ear  were  found  to  be  normal,  save  the  tympanic  membranes,  "  in  which  there  were 
triangular  gaps  extending  from  the  roof  to  just  below  the  centre,  the  bases  of 
the  gaps  being  directed  upward,  and  the  anterior  sides  being  formed  by  the 
handle  of  the  mallei.  The  gaps  appeared  to  be  congenital  and  were  quite  sym- 
metrical." All  the  other  parts  of  the  ear  were  normal.  The  auditory  nerves  were 
•of  normal  size  and  structure. 


MECHANICAL  APPARATUS  FOR  ASSISTING  THE  HEARING. 

The  hearing-trumpet  remains  as  yet  the  best  means,  in  the 
greater  number  of  cases,  of  increasing  the  hearing  power.  The 
audiphone  invented  by  Mr.  Rhodes,  of  Chicago,  is  of  equal  value 
in  some  cases,  and  is  preferred  by  those  who  are  able  to  use  it.  It 
is  more  easily  held,  and  less  conspicuous.  I  think  no  one  is 
benefited  by  a  hearing-trumpet  or  audiphone,  unless  the  loss  of 


FIG.  136.— Hearing-Trumpets. 


FIG.  137.— Auricles. 


hearing  be  due  to  disease  of  the  middle  ear,  or  to  a  want  of 
power  over  the  tympanic  muscles  occurring  in  old  age,  which 
I  would  style  presbykousis.  As  yet,  hearing-trumpets  and  the 
audiphones  must  be  carefully  tested  by  the  patient  himself  be- 
fore it  can  be  certainly  known  that  he  will  be  materially  assisted 
by  them.  I  have  lately  seen  a  case  of  watering  of  the  eyes,  that 
seemed  to  be  caused  by  the  use  of  the  audiphone.  The  patient 
stated  that  great  lachrymation  occurred  whenever  she  used  the 
instrument  for  a  long  period,  which  lasted  for  some  time.  If 
she  did  not  use  it  for  a  few  hours,  the  watering  would  lessen  or 
disappear.  Many  patients  speak  of  the  fatigue  of  listening  with 
a  hearing-trumpet,  while  others  never  seem  to  experience  any 
such  sensation. 


720 


AUDIPHONE. 


The  accompanying  figures  give  a  fair  idea  of  the  general 
form  of  the  most  useful  hearing-trumpets,  and  of  the  audiphone 
and  its  use,  as  well  as  of  the  so-called  auricles.  The  latter  ara 
unsightly  but  of  some  value. 


FiO.  138. — The  Audiphone  in  its  nat- 
ural position ;  used  as  a  fan. 


FIG.  139. — The  Audiphone  in  tension; 
the  proper  position  for  hearing. 


Politzer  has  invented  a  small  instrument  in  the  form  of  a 
hunting-horn,  whose  narrower  inner  end  is  placed  in  the  meatus, 
while  its  outer  and  broader  part  lies  on  the  auricle,  so  that  its 
opening  is  directed  straight  back  against  the  concha.  Politzer 


FIG.  140.— Method  of  Using  the  Audiphone. 

states  that  the  principle  of  his  instrument  is  based  on  the  physio- 
logical fact  that  sound  acting  on  the  ear  is  heard  more  loudly 
when  the  surface  of  the  tragus  is  enlarged  posteriorly  by  plac- 
ing a  small  solid  plate  upon  it.  I  have  not  yet  seen  any  marked 
benefit  to  the  hearing  from  Politzer's  instrument. 


INSTRUMENT   FOR   IMPROVING   HEARING.  721 

One  of  my  patients,  Rev.  Richard  Walsh,  has  lately  invented 
a  hearing-tube,  with  a  mouth-piece  lined  with  cork,  which  seems 
to  have  some  advantages  over  the  ordinary  hearing-trumpets. 
Cork  is  an  excellent  conductor  of  sound.  Walsh's  ear-trumpet 
has  been  patented,  and  is  now  in  the  market. 

I  am  not  without  hope,  as  I  have  already  said  in  this  work, 
that  we  shall  yet  make  an  apparatus  which  will  improve  the 
hearing  of  such  persons  as  are  deaf  from  disease  of  the  middle 
ear,  and  who  hear  well  in  a  noise,  as  well  as  for  those  who  are 
presbykousic.  Those  deaf  from  disease  of  the  nerve,  must  re- 
main without  aid,  just  as  those  who  suffer  from  disease  of  the 
optic  nerve  or  retina  cannot  find  lenses  that  will  enable  them  to 
see. 


DESCRIPTION  OF  THE  CHROMO-LITHOGRAPHS. 


FIG.  1. — Normal  membrana  tympani. 

It  is  impossible  to  exactly  render  the  normal  tint  of  this  beautiful  structure, 
but  this  lithograph  seems  to  me  to  approximate  this  to  a  very  satisfactory 
degree. 

FIG.  2.1 — In  this  case,  that  of  a  man  thirty-two  years  of  age,  a  purulent  in- 
flammation of  the  middle  ear  had  existed  for  nearly  two  years.  There  was  a 
perforation  in  front  of  the  malleus,  which  finally  healed  under  the  application 
of  nitrate  of  silver,  forming  the  cicatrix  shown  in  the  drawing,  and  also  a  small 
circular  opening  through  the  "pars  flaccida" — the  space  within  the  opening, 
and  around  the  malleus-incus  articulation  being  filled  with  small  granulations. 
After  the  closure  of  the  lower  perforation,  these  were  treated  by  application  of 
saturated  solution  of  arg.  nit.  on  a  cotton-tipped  probe,  with  good  result.  The 
outer  layer  of  the  membrana  tympani,  above  and  behind  the  processus  brevis, 
was  much  thickened  and  congested,  and  this  condition  (as  shown  in  the  draw- 
ing) continued  after  the  closure  of  the  inferior  perforation.  This  plate  is  of 
value,  as  exhibiting  a  comparatively  rare  form  and  position  of  perforation  of  the 
membrana  tympani,  and  one  not  readily  amenable  to  treatment. 

FIG.  3  represents  a  small  perforation,  the  consequence  of  purulent  otitis 
media,  occurring  in  a  boy  twelve  years  of  age,  and  of  one  year's  duration. 
There  were  no  granulations  at  the  time  when  the  drawing  was  made,  and  the 
perforation  was  in  process  of  healing,  as  is  shown  by  the  congested  blood-vessels 
extending  from  the  periphery  toward  the  perforation.  This  drawing  exhibits 
the  want  of  clearness  of  the  outline  of  the  malleus,  as  the  result  of  thickening 
of  the  outer  layer  of  the  membrana  tympani,  and  also  the  prominence  of  the 
processus  brevis  and  of  the  posterior  fold,  in  consequence  of  the  concavity  of 
the  membrana  tympani.  Through  the  perforation  is  seen  the  congested  mucous 
membrane  of  the  middle  ear. 

FIG.  4. — A  case  of  purulent  otitis  media,  in  a  boy  twelve  years  of  age.  This 
•  drawing  represents  faithfully  the  granulations  occurring  on  the  membrana  tym- 

1  The  cases  here  described  were  treated  by  Drs.  C.  J.  Blake  and  H.  L.  Shaw,  of 
Boston. 


DESCRIPTION   OF   CHEOMO-LITHOGRAPHS.  723 

pani,  and  also  the  thickening  of  the  membrana  tympani,  subsequent  to  the  per- 
foration, and  during  the  continuance  of  the  purulent  inflammation.  This  case 
was  convalescent  at  the  time  the  drawing  was  made,  under  the  application  of 
astringents  to  the  middle  ear,  and  the  granulations  were  rapidly  diminishing 
under  the  application  of  arg.  nit.  In  this  drawing,  also,  is  shown  the  peculiar 
arrangement  of  the  blood-vessels  passing  from  the  superior  wall  of  the  meatus 
into  the  membrana  tympani,  to  assist  in  forming  the  manubrial  plexus,  and 
which  are  congested  in  consequence  of  the  diseased  condition  of  the  tympanum 
and  membrana  tympani. 

FIG.  5  represents  a  case  of  chronic  catarrhal  inflammation  of  the  middle  ear, 
accompanied  by  great  concavity  of  the  membrana  tympani.  The  processus  bre- 
vis  is  very  prominent,  and  both  anterior  and  posterior  folds  of  the  membrana 
tympani  are  consequently  elongated.  The  handle  of  the  malleus  is  much  fore- 
shortened, and  the  lower  end  nearly  in  contact  with  the  promontorium,  as  is 
shown  by  the  lighter  color  of  the  membrana  tympani  at  this  point,  the  light  rays 
being  reflected  directly  from  the  white  surface  of  the  promontorium.  The  con- 
cavity of  the  membrana  tympani  is  further  evidenced  by  the  character  of  the 
light  reflection,  which,  instead  of  being  a  perfect  cone,  as  represented  in  Fig.  1, 
is  represented  by  two  small  points  of  light,  one  close  to  the  end  of  the  malleus, 
and  one  at  the  periphery  ;  the  intermediate  space  representing  a  surface  of  such 
degree  of  concavity  that  the  light  thrown  upon  it  from  the  mirror  is  focussed  at 
a  point  within  the  meatus. 

FIG.  6  is  a  type  of  cases  of  chronic  catarrhal  inflammation  of  the  middle  ear, 
of  long  standing,  in  which  the  mucous  coat  of  the  membrana  tympani  has  become 
uniformly  thickened,  with  but  a  slight  degree  of  concavity  of  the  membrana 
tympani ;  the  latter  condition  in  this  case  is  principally  evidenced  by  the  prom- 
inence of  the  manubrium  and  processus  brevis,  and  of  the  posterior  fold.  The 
same  dull  gray  color  is  found,  as  a  result  of  thickening  of  the  mucous  coat  of 
the  membrana  tympani,  followed  by  acute  inflammation  of  the  middle  ear. 

This  drawing  exhibits  also  the  appearance  characteristic  of,  and  the  form 
peculiar  to,  large  calcareous  deposits.  The  light  reflex  is  wanting,  in  conse- 
quence of  the  presence  of  the  calcareous  deposit  at  the  point  at  which  this  ap- 
pearance is  found  in  the  normal  membrana  tympani. 

FIG.  7  represents  a  condition  common  to  chronic  catarrhal  inflammation  of 
the  middle  ear.  In  this  case  the  malleus  is  in  contact  with  the  promontorium, 
and  the  continuance  of  the  atmospheric  pressure  from  without  has  carried  the 
membrana  tympani  inward,  rendering  the  malleus  exceedingly  prominent.  The 
light  color  of  the  central  portion  of  the  membrana  tympani  is  due  to  the  reflec- 
tion of  light  from  the  inner  wall  of  the  tympanum,  and  not  to  thickening  of  the 
mucous  coat.  This  condition  is  found  where  the  trouble  has  been  confined 
principally  to  the  mucous  membrane  of  the  Eustachian  tube  and  anterior  portion 
of  the  tympanum,  without  the  thickening  of  the  inner  coat  of  the  membrana 
tympani,  which  is  shown  in  Figs.  5  and  G. 

FIG.  8  exhibits  the  result  of  purulent  inflammation  of  the  middle  ear  of 
long  standing,  in  a  boy  ten  years  of  age.  At  the  time  of  the  drawing  the  dis- 


724  DESCRIPTION  OF  CHROMO-LITHOGEAPHS. 

charge  had  ceased,  under  treatment  with  dry  cotton  packing  applied  daily, 
and  the  mucous  membrane  was  returning  to  a  normal  condition.  There  were 
two  large  perforations,  divided  by  a  narrow  bridge  of  thickened  membrana  tym- 
pani.  The  short  process  of  the  malleus  was  very  prominent,  and  the  manubriuni 
in  contact  with  the  promontory.  The  remainder  of  the  membrana  tympani  was 
much  thickened.  The  slight  congestion  about  the  short  process,  and  along  the 
manubrium,  was  due  to  the  pressure  of  the  cotton  plug,  as  there  was  no  evi- 
dence of  a  process  of  repair  about  the  edges  of  the  perforation. 


N°  2. 


N9  3 


N?  4. 


N9  5. 


N?  7. 


INDEX  OF  AUTHORS. 


Achilini,  5 

Agnew,  0.  R.,  104,  325,  456,  487, 489,  491, 

492,  497,  506,  541 
Agricola,  Rudolphus,  21 
Albini,  O.  S.,  86 
Albutt,  574 
Alcmseon,  4 
Allen,  Peter,  36,  76 
Ambrose,  D.  R,.,  507,  667 
Andrews,  J.  A.,  574 
Apollonius,  15 
Archigenes,  16 
Arcularius  Johannes,  19 
Aristotle,  4 

Arnold,  F.,  11,  205,  234,  253 
Asclepiades,  15 
Aurelianus,  17 
Ausspitz,  118 


Baldwin,  647 

Banze,  Marcus,  22 

Bartlett,  435 

Beard,  George  M.,  408,  483,  681,  706 

Beck,  Karl  Joseph,  25,  28,  102 

Benedetti,  Alexander,  19 

Berengario,  5 

Berger,  27,  536 

Bernard,  Claude,  268 

Berres,  9 

Berthold,  460,  610 

Billington,  C.  E.,  304 

Billroth,  Theodor,  103,  475,  562 

Bing,  58 

Bishop,  Edward,  403 

Blake,  Clarence  J.,  37,  57,  64,  102,  111, 

144,  147,  181,  255,  256,  435,  480,  483, 

484,  654,  688 
Blau.  304,  305 
Bochdalek,  9,  217 
Bock,  11 
Boerhaave,  88 
Boke,  479 

Bonnafont,  11,  37,  406,  423,  486,  585 
Bottcher,  13,  610 
Bowman,  W.,  602,  606 


Boyer,  421 

Bozzini,  66 

Brandeis,  115 

Brendel,  9 

Bremer,  V.,  487 

Breschet,  11,  599 

Briddon,  C.  K,  326 

Brodie,  Sir  Benjamin,  195 

Broca,  563 

Brown,  F.  T.,  515 

Brugsh,  G.,  4 

Brunner,  235,  647,  656 

Buchanan,  Thomas,  11,  28,  177,  421 

Buck,  A.  H.,  18.  36,  46,  106, 136, 138,  156, 
167,  190,  235,  256,  259,  273,  302,  303, 
324,  359,  390,  420,  435,  455,  475,  497, 
498,  506,  542,  560,  607,  656 

Biickner,  124 

Bull,  Charles  S.,  148,  347 

Bull,  George  J.,  707 

Bumsted,  106 

Burkner,  213 

Burnett,  C.  H.,  36,  88,  106,  256,  338,  358, 
390,  436,  584 

Burnett,  S.  M.,  150,  625 

Busson,  Julian,  26,  417 

Butcher,  William,  422 

Buttles,  M.  S.,  406 


Cameron,  557 

Camper,  10 

Capivacci,  19 

Cardan,  Jerome,  21 

Carpenter,  195 

Carpenter,  W.  M.,  326 

Cassebolim,  J.  H.,  9 

Cassells,  J.  Patterson,  37,  390,  303 
I  Casserius.  Julius,  7 
!  Catlin,  396 

Celsus,  15,  474 

Cerlata,  Peter  de  la,  18 

Chassaignan,  562 

Choyan,  563 

Cheselden,  Thomas.  416 

Chimani.  105,  114,  483 

Clarke,  Edward  H.,  35,  194,  482 


726 


INDEX   OF   AUTHOR* 


Clarke,  Lockart,  207,  209 

Claudius,  13 

Cleland,  Archibald,  25,  70 

Cloquet,  11 

Clvmer,  Meredith,  662 

Cock,  Thomas  F.,  334 

Cocks,  David  C. ,  495 

Coggin,  David,  58 

Cohen,  68 

Coles,  371 

Columbo,  6 

Conta,  von,  51 

Cooper,  Sir  Astley,  27,  37.  254,   416,  417, 

418,  423,  436,  449,  543 
Cornwall,  390 
Corti,  Marchese,  13,  609 
Cos,  3 
Cotugno,  9 
Cousins,  127 
Cox,  569 

Crampton,  Sir  Philip,  548 
Crosby,  A.  B.,  541 
Cruveilhier,  676 
Cumberbatch,  679,  718 
Curtis,  John  Henry,  28,  38,  421 
Cutter,  Ephraim,  394 
Cuvier,  6 
Czermak,  67,  370 

D 

Dalby,  W.  B.,  35,  656 

Dalton,  267 

Darling,  William,  196 

Darwin,  88 

Degravers,  417 

Deiters,  13 

Delafield,  F.,  156 

Deleau,  28,  199,  422 

Delechorriere,  301 

De  Vigo,  20 

Dieffenbach,  538 

Dienert,  417 

Dioscorides,  17 

Di  Rossi,  35,  64,  707 

Dominic,  Cotugno,  9 

Draper,  147 

Duchenne,  86 

Du  Verney,  8,  22,  190,  449 

E 

Ebers,  George,  3 

Eisell,  235 

Eli.  417 

Elsberg,  Louis,  69,  188,  385 

Ely,  E.  T.,  99, 162,  312,  317,  322,  369,  396, 

456,  459,  485,  504,  524,  567,  636,  637 
Ely,  W.  S.,  131 
Emerson,  J.  B. ,  54,  156, 164,  361,  502,  622, 

707 

Empedocles,  4 
Eno.  Henry  C.,  470 
Eraaistratus,  4 


Erb.  680 

Erhard,  Julius,  34 

Esser,  87 

Eve,  F. ,  105 

Eustachius,  Bartolomrneus,  4,  6,  2o2 

F 

Fabricius  of  Aquapendente,  7 

Fabricius  of  Hilden,  22,  205 

Fallopius,  Gabriel,  6,  19 

Faruham,  H.  P.,  401 

Field,  George  P.,  36,  349,  491 

Fielitz,  357 

Fischer,  Alexander,  10 

Fisher,  Lewis,  313 

Fisher,  502 

Flint,  Austin,  Jr.,  267 

Follin,  541 

Forest,  Peter,  20 

Fox,  Cornelius  B. ,  207,  209 

Francis,  George  E.,  546 

Frank,  Martel,  31,  62,  104,  389,  420 


Gadesden,  18 

Galen,  4,  5,  15,  16,  501 

Garrod,  121 

Gerlach,  12,  224 

Geynes.  5 

Gibbs,  718 

Goethe,  253 

Goodwillie,  68 

Gottstein,  305 

Graefe,  von,  A.,  643 

Graham,  112 

Green,  John,  264,  437 

Green,  J.  Orne,  18, 144, 151, 190,  208,  270, 
374,  415,  431,  499,  546 

Greenberger,  707,  717 

Griesinger,  675 

Gross,  S.  D.,  167,  189 

Gruber,  Ignaz,  60 

Gruber,  Josef,  9.  34,  75,  83,  94,  128,  182, 
207,  217,  261,  342,  374,  376,  391,  427, 
429,  479,  548,  561,  585,  625.  629,  634 

Gruening,  E.,  116,  121,  183,  486,  487 

Gudden,  110 

Guidi,  18 

Gull,  Sir  William,  564 

Guye,  406 

Guyot,  25,  70 

H 

Hackley,  Charles  E.,  261,  277,  299,  389, 

403,  448,  483,  553 
Haeckel,  88 
Haller,  10 
Hallier,  147 

Hammond,  W.  A.,  325,  641,  653 
,  Harlan,  G.  C.,  656 


INDEX   OF   AUTHORS. 


727 


Harless,  87 

Hartmann,  J.,  21,  37,  431,  468 

Hassenstein,  147 

Hecksher,  203 

Heller,  650 

Helmholtz,  H.,  62,  220,  234,  256,  429,  608, 

624 

Helmont,  von,  22 
Hendriksz,  422 
Henle,  J.,  595,  598 
Hensen,  87,  256,  257,  609 
Heraclides,  15 
Herodotus,  14 
Herophilus,  4 
Hessler,  562,  569,  570 
Hewitt,  Prescott,  570 
Himly,  Karl,  418,  421 
Hinton,  James,  13,  32,  36,  295,  348,  374, 

415,  421,  433,  447,  448,  453,  455,  461, 

540,  656,  675 

Hippocrates,  4,  14,  15,  18,  23,  190 
His,  370 

Hoffman  (of  Westphalia),  33,  62 
Hoffmann,  Friederich,  24 
Hogyes,  610 
Holt,  E.  E.,  76,  358 
Home,  Sir  Everard,  10,  27,  177,  218,  418, 

623 

Horst,  Gisbert,  20 
Houghton,  382 
Hubbard,  Robert,  631 
Hun,  E.  R.,  107 
Hunold,  421 
Hunt,  David,  102 
Hunt,  William,  102 
Huschke,  11,  601 
Hutcliinson,  Jonathan,  571,  630 
Hyrtl,  Joseph,  9,  13,  84,  85,  94,  217,  428, 

595,  607 


Ingrassia,  6 
Itard,  28,  421,  449 


Jackson,  Hughlings,  571,  676,  678 

Jacobi,  A.,  304,  643 

Jacobson,  11 

Jacoby  (of  Berlin),  541 

Jaeger,  Edward,  62 

Jasser,  536 

Johannes,  11 

Jones,  Handfield,  200 

Jones,  H.  Macnaughton,  36 

Jones,  T.  Wharton,  11,  218,  594,  597 

Joux,  Amedee,  97 


K 


Kessel,  Adolph,  475 

Kessel,  J.,  177,  218,  222,  224,  236,  240,  256 

Keyes,  636 


Kinne,  189 

Kipp,  C.  J.,  105,  115,  435,  516,  573 

Kirchner,  648 

Knapp,  H.,  35,   114,  133,  151,  189,  390, 

625,  650,  650,  663,  682 
Koiter,  Volcher,  7 
Kolb,  499 
Kolliker,  13,  602 
Koeppe,  205 
Koppe,  246,  541 
Kramer,  W.,  28,  60, 151,  357,  364,  373,  403, 

406,  423,  613,  706 
Krause,  235 
Kuchenmeister,  143 
Kupper,  88,  205,  305 


Lallemand,  565 

Langenbeck,  190 

Lavater,  97 

Lebert,  565,  570 

Lewis,  F.  N.,  507 

Lewis,  W.  B.,  148 

Liel,  Weber,  35,  141,  198,  402,  414,  410, 

427,  428,  439,  484,  571,  647 
Lincke,  3,  4,  24,  37,  599 
Listen,  410 
Little,  J.  L.,  655 
Loomis,  A.  L.,  326,  331 
Loring,  E.  G.,  64,  107,  272,  316,  389,  494, 

501,  556,  627 

Lowenburg,  140,  151,  194,  370,  456 
Lucae,  Augustus,  12,  13,  57,  257,  355,  432, 

467,  650 
Luschka,  649 
Lusitanus,  21 
Lussana,  610 

M 

Macewen,  566 

Mach,  55,  87,  255,  256 

Maclagan,  206 

Magnus,  12,  264,  367,  437,  438 

Marcellus,  17 

Marinus,  4 

Mathewson,  A.,  34,  299,  389,  435,  402,  437, 

490,  495 
Maunoir,  420 
Mayer,  Ludwig,   143,   178,  197,  203,  250, 

252.  254,  346,  541 
McKay,  557 
McKeown,  435 
Meckel,  10,  11 
Meiiiere,  13,  276,  677 
Merian,  Burkhardt,  467,  499 
Merkel,  253 
Merrell,  316 
Metcalfe,  John  T.,  313 
Meyer  (of  Hamburg),  111 
Meyer,  Wilhelm,  369,  371 
Michael,  468 
Michaelis,  420 


728 


INDEX   OF   AUTHORS. 


Millinger,  461 

Miot,  37 

Moldeiihauer,  190 

Monro,  Alexander,  10 

Moos.  S.,  13,  34, 35,  222,  365,  374,  447, 486, 

487,  499,  609,  625,  634,  649,  650,  656, 

681 

Morgagni,  8,  10,  538,  565 
Morgan,  Lewis  H. ,  397 
Miiller,  Johannes,  11,  354,  479 
Munk,  610 
Mussey,  105 


Newbourg,  60 

Newton,  Homer  G. ,  34,  561 

Niemeyer,  677 

North,  Alfred,  492 

Noyes,  H.  D.,  330,  373,  407,  426,  435 


o 


Ormerod,  678,  679 


Pacini,  143 

Pagenstecher,  540 

Paget,  Sir  James,  544 

Pappenheim,  234 

Paracelsus,  19 

Pardee,  C.  L,  390,  399,  463,  494 

Pare,  Ambrose,  20,  464 

Patruban,  9,  216 

Paul  of  ^Egina,  17,  190 

Paullini,  23 

Pechlin,  204 

Peters,  George  A.,  387,  555,  571 

Petit,  Antoine,  26 

Petit,  J.  L.,  24,  537 

Petrequin,  J.  E.,  176 

Pierce,  175 

Piffard,  H.  G.,  389 

Pilcher,  George,  30,  200 

Pinkney.  Howard,  438 

Pissot,  301 

Pliny,  4,  17,  474 

Plutarch,  4 

Politzer.  Adam,  9,  13,-  33,  34,  37,  45,  55, 
56,  57,  74, 105,  139, 167, 189,  204,  214, 
217,  219,  221,  235,  237,  256,  257,  260, 
306,  309,  343,  355,  363,  390,  415,  416, 
432,  435,  453,  458,  467,  483,  610,  720 

Pollak,  214,  552 

Pomeroy,  O.  D.,  37,  106,  114,  167,  300, 
347,  389,  393,  415,  481,  547 

Pooley,  T.  R.,  115 

Portal,  417 

Post,  Alfred  C.,  499,  501,  539,  561 

Prescott,  Royal,  312 

Pritchard,  U.,  457.  679 

Prout,  J.  S.,  48,  406,  432,  462 


Prussak,  222 
Pythagoras,  4 


Quain,  207 


Ramsdell,  E.  B.,  587 

Ranke,  609 

Rankin,  F.  H.,  157,  401,  455 ' 

Ranney,  A.  L.,  560,  608 

Rau,  30,  358,423 

Reid,  James,  410 

Reiner,  37 

Reynolds,  Russel,  679 

Rhazes,  18 

Riber,  420 

Rice,  Clarence  C.,  397 

Rider,  456 

Richeraud,  436 

Ringer,  S.,  139 

Rinne,  88 

Riolanus,  416,  537 

Rivinus,  8 

Robertson,  Charles  A.,  479,  484 

Robinson,  Beverley,  371,  390 

Rockwell,  A.  D.,  408,  681 

Rohland,  288 

Riidinger,  34,  234,  247,  250,  254 

Rufus  (of  Ephesus),  4 

Rumbold,  390 

Rushmore,  274,  420 

Russell,  209 

Ruysch,  9 


Sabatier,  417 

Saissy,  J.  A. ,  28,  422,  436 

Sands,  H.  B.,  326 

Sappey,  90,  92,  207 

Sassonia,  Hercules,  20 

Saunders,  J.  C.,  10,  27,  37,  421 

Savage,  410 

Scarpa.  Antonio,  10 

Schalle,  204 

Schaar,  57 

Scheibenzuber,  182 

Schlemm,  11 

Schmiedekam,  261 

Schmiedel,  9 

Schneider,  87 

Schultze,  Max,  599 

Schwartze,  Herman.  13,  27,  34,  56,  103, 
143,  190,  205,  288,  300,  346,  374,  378, 
416,  417,  420,  421,  422,  424,  453,  460, 
483,  497,  506,  541,  542,  629,  676 

Seebeck,  255 
!  Seligman,  Professor,  487 
;  Semeleder,  67,  370 


INDEX   OF   AUTHORS. 


729 


Sequard,  Brown,  111 

Serapion,  18 

Sexton,  Samuel,  89,  320,  555,  560,  682 

Shaw,  Henry  L.,  270,  390,  551 

Shrapnell,  11,  216,  265 

Simrock,  277 

Sirns,  J.  Marion,  196 

Smith,  Andrew  H.,  262,  437 

Smith,  Gouverneur  M. ,  301 

Smith,  J.  Lewis,  651 

Smith,  Nathan  R. ,  422 

Smith,  Thomas,  106 

Soemmeriug,  Thomas  George,  11,  234 

Speir,  E.  D.,  196 

Spencer,  W.  D.,  313 

Steinbrugge,  13,  609 

Stenon,  Nicholaus,  8 

Sterling,  George  A.,  566 

Steudener,  F.,  148 

Stevenson,  421 

Strawbridge,  542 

Sutton,  564 

Swieten,  Van,  25 

Swift,  Foster,  381,  571 


T 


Tagliacottzi,  Caspar,  21 

Tait,  Lawson,  718 

Tangeman,  460 

Tansley,  J.  O.,  75,  337 

Taylor,  R.  W.,  106 

Taylor,  Fayette  C.,  128 

Teole,  10 

Teulon,  Giraud,  64 

Theobald,  S.,  349,  381,  435,  542,  560 

Thudichum,  385 

Thurman,  110 

Tod,  David,  10 

Todd,  Robert  B.,  302,  606 

Tortual,  253 

Toynbee,  Joseph,  11,  12,  13,  32,  33,  60,  74, 
110,  162,  205,  254,  257,  266,  364,  374, 
375,  381,  423,  465,  488,  489,  539,  551, 
568,  656,  706 

TrSltsch,  Anton  von,  12,  13,  18,  23,  32,  34, 
47,  60,  61,  96,  128,  169,  181,  190,  204, 
207,  222,  223,  235,  236,  237,  250,  254, 
266,  276,  287,  330,  339,  342,  346,  357, 
364,  365,  374,  385,  403,  413,  423,  455, 
466,  490,  537,  539,  607,  613,  650,  676, 
688 

Tiirck,  66,  370 

Turnbull,  Lawrence,  35,  408,  540 

Turner,  487 


t 


Dibantschitsch,  37,  204,  408 


Valleroux,  Hubert,  422 

Valsalva,  Autoine  Maria,  2,  8,  9,  12,  24, 

77,  253,  537 
Van  der  Hoeven,  10 
Varolius,  Constant,  7 
Velpeau,  243 

Vesalius,  Constant,  5,  6,  7 
Vieussens,  Raymond,  8 
Virchow,  Rudolph,  109,  476,  489 
Virsinier,  647 
Vogel,  I.,  143 
Voltolini,  Rudolph,  13,  34,  67,  185,  220, 

235,  370,  374,  427,  432,  549,  629,  649, 

663,  688 

W 

Wakely,  T.,  166 

Waldeyer,  604 

Wallis,  John,  23 

Walther,  9 

Watham.  Jonathan,  26 

Weber,  C.  O.,  484 

Weber,  E.  H.  (Leipsic),  11,  55,  384 

Weber,  Theodore,  384 

Webster,  David,  174,  367,  502 

Weir.  Robert  F.,  69,  94,  156,  265,  276,  303, 

328,  407 
Welch,  156,  317 
Welcker,  H.,  487 
Wendt,  235,  304 
Wilde,  Sir  William,  2,  31,  38,  60,  66,  110, 

166,  181,  206,  287,  340,  357,  364,  374, 

381,  417,  422,  447,  449,  479,  500,  538, 

561,  613 

Williams,  Joseph,  30 
Williams,  A.  D.,  35,  132 
Willis,  Thomas,  22,  356 
Wilson,  F.  M.,  92,  189 
Winslow,  10 

Woakes,  36,  208,  440,  584 
Wood,  John,  181,  207 
Wollaston,  254,  622 
Wreden,  Robert,  143,  147,  151,  180,  304, 

402,  427,  574 
Wrieht,  C.  E.,  347 
Wyman,  488 


Yale,  L.  M.,  645 
Yearsley,  James,  30,  465 


Zaufal,  68 
Ziemssen,  86 
Zinn,  9 

Zoja.  Giovanni.  243 
Zuckerkandl,  E.,  240 


INDEX  OF  SUBJECTS. 


A  BSCESS  of  cerebrum,  474,  563,  566 
J\.     of  mastoid,  505 

of  membrana  tjmpani,  308 
of  neck,  524 
Acoumeter,  45 
Acoustic  nerve,  4 

Actual  cautery  in  uon  suppurative  inflam- 
mation, 427 

Adenoid  vegetations  in  pharynx,  370 
Adhesions  in  middle  ear,  474 
Aerial  conduction  of  tuning-fork,  54,  353, 

621 
Air,    atmospheric,  through   catheter,   73, 

399 

Air-bubbles  in  chronic  catarrhal  inflam- 
mation, 344 
in  perforation  of  the  membrana  tym- 

pani,  445 

Air,  condensed,  effect  of,  263,  437 
Air,  exhaustion  of,  from  external  auditory 

canal,  437 
Alchohol  in  suppuration  of   middle  ear, 

456,  458,  481 
Albuminuria  from  chronic  suppuration  of 

middle  ear,  448 
Alum  powder  in  chronic  suppuration  of 

middle  ear,  456 

American  Otological  Society,  34 
Anatomy  of  ear,  progress  in.  4 
Anchylosis  of  malleus  and  incus,  4,  375 

of  stapes,  375 
Aneurism,  673 
Angiomata,  105,  476 

cases  of,  121 

Angioma  cavernosum.  476 
Anodynes,  130,  138,  290,  320,  585 
Anterior  rhinoscopy,  68 
Anti-helix,  82 

Antiphlogistic  treatment,  323 
Anti-tragus,  4,  82 

muscles,  84 

Antrum  mastoideum,  239 
Annulus  tympanicus,  92,  222 
Aquseductus  Fallopii,  6,  230 
Artificial  membrana  tympani,  30,  465 
Aspergillus, 

cases  of,  142,  151-154 


Aspergillus, 

causes  of,  145 

symptoms  of,  146 

statistics  of,  445 

treatment  of,  150 

varieties  of,  146 
Astringents, 

in  acute  suppuration  of  middle  ear, 
320 

in  chronic  inflammation  of  external 
canal,  136 

in  chronic  suppuration  of  middle  ear, 
456 

in  eczema,  120 

Atropia  in  diffuse  inflammation  of  audi- 
tory canal,  133 
Attollens  auriculam,  83 
Attrahens  auriculam,  83 
Audiphone,  720 
Auditory  canal,  external, 

abscess  of,  cases  of,  169 

affections  of,  123 

anatomy  of,  90 

angles  formed  with  membrana  tym- 
pani, 92 

blood-vessels  of,  96 

caries  of  bones  of,  156 

cast  of,  92 

chronic  inflammation  of,  136 

chronic  suppuration  of,  1 37 

circumscribed  inflammation  of,  137 

closure  of,  18,  155 

condylomata  of,  154 

curvatures  of,  91 

desquamative  inflammation  of,  137 

diffuse  inflammation  of,  124 
anodynes  used  in,  131 
cases  of,  extending  to  tympanum, 

335 

causes  of,  126,  311 
incisions  in,  136 
objective  symptoms  of,  125 
popular  remedies  for,  131 
resume  of  treatment  for,  132 
subjective  symptoms  of,  124 
treatment  for,  128 

diphtheritic  inflammation  of,  155 


732 


INDEX   OF  SUBJECTS. 


Auditory  canal,  external, 
eczema  of,  117 
examination  of,  59-64 
foreign  bodies  in,  179 
furuncles  of,  137 

causes  of,  137,  140 

treatment  of,  138 
inspissated  cerumen  in,  158 
length  of,  92 
lining  of,  93 

lower  animals,  comparison  of,  94 
narrowing  of,  155 
nerves  of,  96,  207 
ossification  of,  94 
of  dogs  and  cats,  94 
parasitic  inflammation  of,  143 

cases  of,  144 

causes  of,  145 

symptoms  of,  146 
physiology  of,  96 
polypi  in,  126,  489 
relations  of,  95 
sarcoma  of,  156 
statistics  of  affections  of,  125 
suppuration  of,  137 

cases  of,  with  inspissated  cerumen, 

174 

syphilitic  ulcers  of,  154 
nlceration  of,  136 
Auditory  canal,  internal,  4,  606 
Auditory  nerve, 

atrophy  of,  617 

cases  of,  617-619 
concussion  of,  cases  of,  673 
distribution  of,  10,  603 
disease  of,  from  cerebro-spinal  menin- 
gitis, 649 

cases  of,  651 
inflammation  of,  617 
inflammation  of,  from  meningitis,  652 

cases  of,  652 
origin  of,  604 
.  primary  disease  of,  614 

cases  of,  617-619 
treatment  of  diseases  of,  620 
Aural  clinics,  37 

Aural  disease,  extending   from  the  pha- 
rynx, 38,  65 

in  constitutional  disease,  310,  331 
first  successful  system  of  treating,  32 
hallucinations  in,  346 
hemorrhage  in  Bright's  disease,  cases 

of,  300 
Aural  douche,  14,  128,  319 

syringe,  133 
Auricle, 

absence  of,  in  mammalia  living    in 

water,  84 
anatomy  of,  81 
aneurism  of,  105 
angiomata  of,  105 

cases  of,  121 


Auricle, 

arrested  development  of,  101 

artificial,  719 

blood-vessels  of,  86 

calcareous  formations  in,  121 

chondritis  of,  113 
treatment  of,  116 

deformity  of,  101 
cases  of,  102 

detachment  of,  for  removal  of  foreign 

body,  190 
cases  of,  191 

ear-rings  causing  tumors  of,  103 

eczema  of,  117 

epithelioma  of,  116 

erysipelas  of,  120 

fibro  cartilaginous  tumors  of,  103 

fistula  of,  102 

horny  growths  of,  106 

indicative  character  of,  97 

inflammation   of,   from  wearing   ear- 
rings, 83 

injuries  of,  121 

intrinsic  muscles  of,  84 

malformation  of,  98 

movements  of,  86 

muscles  of,  83 

mutilation  of,  supposed  by  ancients  a 
cause  of  sterility,  22 

myxo-fibromata  of,  104 

nerves  of,  87 

operation   for   fibro  cartilaginous  tu- 
mors of,  104 

othsematomata  of,  107 

perichondritis  of,  113 
treatment  of,  116 

physiology  of,  87 

plastic  operation  on,  99 

prominence  "of,  98 
operation  for,  99 

sarcoma  of,  117 

sebaceous  tumors  of,  104 

superfluous,  101 

syphilis  of,  106 

tumors  of,  103 

vascular  tumors  of,  107 
Aurilave,  127,  165 

Authorities  consulted  in  historical  sketch, 
39 

"DINOCULAR  otoscope,  64 

_D     Bleeding  from  the  ears  in  fracture  of 
temporal  bone,  272 

Blisters  in  acute  suppuration  of  middle 

ear,  320 

in  auditory  disease,  132 
in  disease  of  internal  ear,  681 
in  non  suppurative  inflammations,  382 

Blood-letting,  local,  128,  287,  302,    319, 
381,  499,  681 

Boiler-makers'  deafness,  360,  666 
cases  of,  669-672 


INDEX   OF   SUBJECTS. 


733 


Boiler-makers'  deafness, 

causes  of,  667 

complicated  with,  aural  catarrh,  667 

pathology,  668 

resume  of  knowledge  of,  673 

treatment  of,  680 

tuning-fork  test  in,  668,  670 
Bone  conduction  in  aural  disease,  54,  353, 

622 

Bony  growths,  485 
Boracic  acid,  456 
Bougies,  danger  of  use  of,  77,  405 
Bright's  disease, 

cases  of  cerebral  hemorrhage  in,  300 


/CALCAREOUS  formation  in  auricle,  121 
\J     in  membraua  tympani,  365 
Canal,  external  auditory,  90 

diseases  of,  123 
Canal,  internal  auditory,  4,  606 

growths  in,  680 
Canalis  reunicus,  600 
Carcinoma  in  the  tympanum,  479 
Caries  of  auditory  canal,  1 56 

mastoid,  500,  505 

petrous  bone,  557 

teeth,  584 

temporal  bone,  24,  545 

treatment  of,  559 

tympanic  process,  156 
Catarrh  of  middle  ear,  acute,  278 

chronic,  343 

sub-acute,  293 

Cats,  congenital  deafness  of,  718 
Cauterization  of  the  pharynx,  383 

of  polypi,  456 
Caustics,  458,  481 
Cerebral  abscess,  455,  563 

cases  of,  tabulated,  576-582 
Cerebral  symptoms,  from  inspissated  ceru- 
men, 175 

cases  of,  169 
Cerebral  tumors,  673 
Cerebro-spinal  meningitis,  causing 

acute  catarrh  of  middle  ear,  285 

acute  suppuration  of  middle  ear,  310 

deaf-muteism,  306,  710 

disease  of  acoustic  nerve,  649 

proliferous  inflammation   of   middle 

ear,  378 
Cerumen, 

absence  of,  163 

composition  of,  176 

function  of,  176 

increased  formation  of,  in  disease,  160 

inspissated,  158 
cases  of,  168-175 

removal  of,  166 
Ceruminous  glands,  93 
Chloroform,  use  of,  406 
Cholesteatoma,  475,  479 


Chorda  tympani  nerve,  217,  226,  238 

section  of,  435 

injury  of,  266 
Chromic  acid,  482 
Chromo- lithographs,  722 
Cicatricial  membrana  tympani,  463,  474 
Circumscribed  inflammation   of   external 

ear,  123,  137 

Climate  in  aural  disease,  441 
Cleansing  the  ears,  method  of,  134,  451 
Cochlea,  8,  9,  10 

anatomy  of,  595 

disease  of,  614 
treatment  of,  680 

physiology  of,  608 

syphilis  of,  630 
Cochlear  nerve,  605 
Cochlitis,  620 

cases  of,  634 

Cold  in  the  head,  neglect  of,  297 
Concha,  82 
Concussion  of  labyrinth,  666 

cases  of,  669,  673 
Concave  mirror,  63 
Condensed  air,  263,  437 
Condylomata,  154 

Congenital  deafness  of  white  cats,  719 
Constitutional  disease  in  aural  disease,  15, 

310,  331 

Conversation,  test  for  hearing,  45 
Corti's  organ,  602 
Corti's  rods,  13,  602 
Cotton  as  artificial  membrana  tympani,  4G5 

as  a  cleansing  agent,  454 

plugging  the  ears  with,  in  sea-bathing, 
127 

styptic,  288,  482 
Crista  acustica,  599 
Cupping  external  auditory  canal,  437 


D 


EAF-MUTEISM,  685 
cases  of,  tabulated,  690-705 
cases  in  which  words  could  be  heard 

through  speaking-tube,  tabulated, 

716 

causes  of,  687,  706 
caused  by  cerebro  spinal  meningitis, 
710 

cholera  infantum,  715 

convulsions,  713 

fall,  712 

fever,  716 

gastric  fever,  715 

hydrocephalus,  713 

intermittent  fever,  715 

measles,  709 

mumps,  716 

pneumonia,  714 

scarlet  fever,  709 

spinal  meningitis,  714 

syphilis,  713 

varioloid,  714 


734 


INDEX  OF  SUBJECTS. 


Deaf-muteism, 

caused  by  whooping  cough,  715 

congenital,  711 

education  of,  20,  23 

examination  of,  with  tuning-fork,  708 

forms  of,  685 

treatment  of,  689 
Deafness,  absolute,  620 

not  observed  on  account  of  occupa- 
tion, 342 

supposed  incurable,  14,  18,  19 
work  of  the  devil,  22 

to  certain  tones,  624 
Delstanche's  masseur,  439 
Dentition,  282,  584 
Detachment  of  auricle,  18,  190 

cases  of,  191 

Determination  of  direction  of  sound,  611 
Diagnosis,  differential,  of  middle  and  in- 
ternal ear,  352 

tube,  73,  373 
Diffuse  inflammation  of  external  auditory 

canal,  124 
Diphtheritic  panotitis,  305 

inflammation  of  middle  ear,  303 
Diplakousis,  625 
Disease  of   brain  from  aural  disease,  20, 

200,  273,  312,  445,  495,  575 
Disease  of  middle  ear  and  labyrinth,  621 
Disproportion   in   hearing   the   tick  of   a 

watcli  and  human  voice,  49,  615 
Dobell's  solution,  393 
Double  hearing,  625 
Douche,  aural,  128,  319 

nasal,  309,  384 
Dropsy  of  middle  ear,  338 
Ductus  cochlearis,  600 


EAR-ACHE,  ancient  treatment  of,  14-17 
I     Ear-cough,  204 
Ear-drops,  23 

Ear-disease,  neglect  of,  291,  341 
Ear  muffs,  127 
Ear-protectors,  127 
Ear-rings,  tumors  from  use  of,  104 
Ear-sand,  599 
Ear-spoon,  15 
Eczema  of  auricle,  117 

of  auditory  canal,  117          , 

statistics  of,  445 
Electric  light,  use  of,  63 
Electricity  in  diagnosis,  630 

in  non-suppurative  inflammation  of 
middle  ear,  408 

in  disease  of  labyrinth,  681 
Eminentia  stapedii,  236 
Emphysema  from  catheterization,  409 
Endolymph,  599 

Entotic  application  of  hearing-trumpet,  58 
Epilepsy  from  aural  disease,  178,  205,  679 

cases  of.  205 


Epithelioma  of  auricle,  116 
of  middle  ear,  475,  479 
Erysipelas  in  aural  disease,  546 

of  auricle,  120 
Eustachian  catheter,  69 

cause  of  coming  into  disrepute,  26 
danger  in  using,  408 
difficulty  in  introducing,  72,  373 
discovery  of,  25 

in  chronic   non  -  suppurative  inflam- 
mation, 372 
introduction  of  astringents  through, 

401 

method  of  using,  70 
Eustachian  tube, 
anatomy  of,  244 
blood-vessels  of,  77,  252 
bougies  for  dilating,  405 
broken  catheter  in,  204 
changes  in,  369 
closure  of,  24,  372 

diagnostic  tube  in  examination  of,  73 
escape  of  pus  through,  310 
examination  of,  69 

with  bougies,  77 

catheter,  69 

Politzer's  inflation,  74 

Valsalva's  inflation,  77 

probes,  25 

rhinoscopy,  67 
first  description  of,  6 
first  catheterization  of,  25 
foreign  bodies  in,  180,  203 

case  of,  203 
function  of.  247,  257 
history  of  discovery  of,  6,  252 
inflation  of  tympanum  through,  73 
in  infants,  247 
injections  of,  25,  39 
means  of  examination  of,  69 
measurements  of,  244 
muscles  of,  249 
naming  of,  7 
nebulizer  for,  404 
nerves  of.  252 

opened  by  act  of  swallowing,  74 
shape  of,  28 
smoking  through,  416 
spraying  through,  403 
treatment  of,  in  aural  disease,  398 
vapors  in  treating,  28,  399 
Examination  of 

auditory  canal,  59 
membrana  tympani,  60 
patients,  44 

the  ear  by  sunlight.  29,  63 
Exhaustion  of  air  in  auditory  canal,  437 
Exostosis,  164,  447,  485 
cases  of,  491-495 
causes  of,  488 
inflammatory,  488 
in  skulls  of  Indians,  487 


INDEX   OF   SUBJECTS. 


735 


Exostosis, 

treatment  of,  490 

External  auditory  canal, 
anatomy  of,  90 
diseases  of,  123 

External  ear,  79 

Eyelet,  Politzer's,  426 


FACIAL  paralysis,  199,  446,  571 
Facial  nerve,  6,  231 
Fainting  from  syringing,  452 
Faucial  catheter,  394 
Febrile  symptoms  in  acute  aural  catarrh, 

284 
Fenestra  ovalis,  6,  8,  229 

rotunda,  10,  229 
Fibromata,  475 
Fistula  of  auricle,  102 

mastoid,  523 

Fluids  through  Eustachian  catheter,  401 
Fluid  treatment  of  chronic  suppuration  of 

middle  ear,  456 
Foramen  of  Rivinius,  9,  218 
Forceps,  angular,  59 
Foreign  bodies  in  the  ear,  179 
case  of,  196 

causing  cerebral  symptoms,  199 
epilepsy,  199,  205 
facial  paralysis,  199 
hemiplegia,  200 
inspissated  cerumen,  164 
polypi,  200 
danger  of  indiscreet  treatment,  185, 

193,  200 

death  resulting  from  removal  of,  200 
detachment  of  auricle  for,  193 

cases  of,  191,  193 
diagnosis  of.  203 
different  kinds  of,  180,  198 
hairs  of  canal  on  membrana  tympani, 

202 

inanimate,  183 
molten  lead,  200 
reflex  symptoms  from.  204 
removal  of,  16,  22,  186,  194,  198 
statistics  of,  179,  197 
supposed,  185,  201 

Toynbee's  artificial   membrana  tym- 
pani as,  189 

treatment,  184,  186,  202 
Forehead  band,  63 
Forficula  auricularis,  181 
Fossa  navicularis,  82 
sigmoidea,  239 
triangularis,  82 
Fracture  of  handle  of  malleus,  276 

temporal  bone,  272 

French  chalk  in  chronic  suppuration,  455 
Fungus  in  solutions,  459 
Furuncles  in  auditory  canal,  137 
Fused  nitrate  of  silver,  461 


nALVANISM   in   disease   of  labyrinth, 

VJ     681 

Galvano-cautery,  483 

Gargles,  393 

Gargling,  Von  Troltsch's  method  of,  393 

General  treatment  of  aural  disease,  290 

Glands,  ceruminous,  8,  93 

Glycerine,  166 

Granulations,  458,  482 

Graphium  pencilloides,  146 

Gummata,  680 

TJ  ABENULA  tectu,  602 
JiL     Haematoma,  107 
Hairs  on  membrana  tympani,  202 
Hallucinations,  178,  346 
Harmonium  test  for  hearing,  58 
Hearing  better  in  a  noise,  22,  355,   363, 
625 

cases  of,  356.  359,  362 

double,  625 

echo,  628 

tests  of,  45 

trumpet  for,  719 

not  lost  by  absence  of  membrana  tym- 
pani, 24,  450 

disproportion  of  watch  and  voice  test, 

49,  615 
Helicis  major  muscle,  84 

minor  muscle,  84 
Helicotrema,  9,  597 
Helix,  4,  81 
Hemorrhage  in  auditory  canal,  273 

in  caries  of  temporal  bone,  562 

in  internal  ear,  666 
Hemorrhagic  inflammation  of  middle  ear, 

297 

Hot  water  as  a  styptic,  484 
Hydro-tympanum,  337 
Hygiene  in  aural  disease,  382,  412,  440 
Hyperostosis,  164,  485 

TLLUMINATIOX  of  the  ear,  61,  G3 

J_     Incisurse   majoris  articula3  Santorini, 

85,  91 

1  Incus,  232 
:  Infirmary  for  treatment  of  ear  diseases, 

28 

Inflation  of  middle  ear, 
effect  of,  74 
in  children,  74 

in  diseases  of  internal  ear,  616 
Politzer's  method,  33.  74 
modifications  of,  75,  76 
Valsalva's  method,  77 
with  catheter,  73 
Insanity,  vascular  tumors  in,  107 
Insects  in  the  ear,  181 
Inspissated  cerumen, 
cases  of,  168-175 
causes  of,  163 
diagnosis  of,  obsciired,  160 


736 


INDEX   OF   SUBJECTS. 


Inspissated  cerumen, 

frequency  of  occurrence,  158 

mental  depressions  from,  100,  178 

pain  caused  by,  161 

proper  classification  of,  159 

statistics  of,  158,  176 

structure  of,  174 

suppuration  with,  162 

symptoms  of,  160 

symptom  or  result  of  disease,  158 

treatment  of,  166 
ancient,  21 

tuning-fork  test  in,  161 
Inspissated  mucus,  483 
Internal  auditory  canal,  606 
Internal  ear,  591 

anatomy  of,  591 

blood-vessels  of,  607 

diagnosis  of  diseases  of,  by  electricity, 
630 

disease  of,  from  spinal  cord  and  me- 
dulla disease,  typhoid  fever  and 
scarlet  fever,  654 

disease  of,  from  parotitis,  655 

diseases  of,  612 
pathology  of,  679 

hemorrhage  into,  664 

inflammation  of,  662 

injuries  of,  665 

necrosis  of,  548 

physiology  of,  607 

symptoms  of  primary  disease  of,  614 

syphilis  of,  630 

treatment  of  diseases  of,  680 
Intra-auricular  pressure,  13 
Iodine  vapor,  399 
lodoform,  456,  483 
Iter  chordae  anterius,  228 

posterius,  228 

TACOBSON'S  nerve,  9 
U     Jugular  vein,  451 

T7ONIANTRON,  440 

T  ABYRINTH, 
Jj    acute  inflammation  of,  662 
anatomy  of,  591 
anaemia  of,  684 
concussion  of,  666 
differential  diagnosis  of   diseases  of, 

621 

effects  of  quinine  on,  641 
effusion  into.  664 

case  of,  665 
first  mentioned,  5 
fluid  of,  9 

hemorrhage  into,  664 
injuries  of,  665 

cases  of,  665 
leeches  in  disease  of,  681 


Labyrinth, 

membranous,  598 

pathology  of  disease  of,  679 

periosteum  of,  598 

sounds  painful  in  disease  of,  628 

symptoms  of  primary  disease  of,  6C9 

syphilis  of,  630 
cases  of,  631 

tonics  in  disease  of,  681 

treatment  of  disease  of,  680 
Lamina  spiralis  ossea,  597 
Lamps  for  aural  work,  63 
Larvae  in  the  ear,  181 
Lateral  sinus,  pus  in,  558 
Laxator  tynapaui  muscle,  7 
Leeches  in, 

acute  catarrh  of  middle  ear,  287 

acute  suppuration  of  middle  ear,  319 

circumscribed  inflammation  of  audi- 
tory canal,  138 

diffuse     inflammation     of     auditory 
canal,  128 

disease  of  labyrinth,  681 

mastoid  periostitis,  499 
Levator  auriculum,  83 
Levator  veli  palati,  251 
Ligamentum  incudis  superius,  234 

mallei  anterius,  234 

mallei  superius,  234 

obturatorium  stapedis,  234 

spirale,  602 
Light  spot, 

cause  of,  218 

in  non-suppurative  inflammation,  8G6 

measurements  of,  219 

modifications  of,  220 

normal,  365 
Lobe,  83 

Local  antiphlogistic  treatment.  323 
Lung  disease  in  ear  troubles,  377 

MACULA  acustica,  599 
Maculae  cribrosae,  592 
Malaria  a  cause  of  aural  neuralgia,  585 
Malformation  of  auricle,  97 
Malignant  growths,  116,  479,  680 
Malingering,  58 
Malleo-incus  joint,  234 
Malleus,  5,  232 

fracture  of,  276 
handle  of,  218 
Manubrium,  232 
Mastoid, 

abscess  of,  496,  505,  521 
anatomy  of,  238 
blood-vessels  of,  243 
cells  of,  239 
caries  of,  505 
cases  of,  509-525 
first  operation  for,  25 
treatment  of,  506 
development  of,  243 


INDEX   OF   SUBJECTS. 


737 


Mastoid, 

enlargement  of  glands  of,  501 

hyperostosis  of,  497 

indications  for  trephining,  443 

in  acute  suppuration,  811 

lining  of  cells,  240 

oedema  of,  499 

periostitis  of,  496 
cases  of,  502 
dangers  of,  498 
treatment  of,  499 

sclerosis  of,  497 

septicaemia    and    pyaemia    following 
disease  of,  544 

statistics  of  cases  of  disease  of,  508, 
527-535 

trephining,  history  of,  536 

varieties  of,  241 

Wilde's  incision,  500 
Meatus  auditorius  externus,  82 

interims,  5 
Mechanical  apparatus  for  assisting  hearing, 

719 

Membrana  basilaris,  601 
Membrana  flaccida.  11,  216 
Membrana  tympani, 

abscess  of,  309 

artificial,  22,  30,  465 

attachment  of  malleus  to,  222 

bulging  of,  283 

calcareous  degeneration  of,  365 

case  of  direct  violence  to,  272 

changes  in   mobility  in  non-suppura- 
tive  inflammation,  367 

color  of,  219 

condition  in  acute  catarrh,  282 

cyst  of,  259 

diameters  of.  214 

diseases  of,  259 

effect  of  inflation  on,  74 

examination  of,  59 
on  cadaver,  261 

first  described,  4 

function  of,  254 

Hinton's  operation  on,  434 

inclination  of,  213 

inflammation  of,  335 

injuries  of,  259,  265-275 
case  of,  269 

layers  of,  221 

light  spot  of,  218,  365 

loss  of,  not  a  cause  of  total  deafness, 
22,  417 

lymphatic  vessels  of,  226 

measurements  of,  213 

minute  anatomy  of,  221 

nerves  of,  224 

normal,  218 

objects  for  observation  on,  218 

openings  in,  8,  216 

ossification  of,  366 

paracentesis  of,  27,  288,  431 


Membrana  tympani, 

perforation  of,  30,  309,  415,  445 

pigmentation  of,  366 

position  of,  213 

Front's  operation  on,  433 

pulsation  of,  283 

resisting  power  of,  262,  265 

rupture  of,  260,  266,  272 
cases  of,  262 

scarification  of,  288 

secundarius,  229 

shape  of,  215 

structure  of,  11,  213 

sunken,  365 

thickness  of  221 

vascular  tumor  of,  302 
Membrana  reticularis,  604 

vestibularis,  602 
Membranous  labyrinth,  598 
Meniere's  disease,  345,  633 
Meningitis,   cases  of,  from    inflammation 

of  ear,  312,  316 

Mental  depression  from  inspissated  ceru- 
men, case  of,  162 
Microtia,  100 
Microzotes,  141 
Middle  ear,  acute  catarrh  of,  278 

bulging    of    membrana  tympani  in, 
283 

causes  of,  284 

course  of,  292 

febrile  symptoms  in,  284 

hearing  in,  283 

hot  douche  in, 287 

induced  by  quinine,  286 

leeches  in,  287 

mastoid  complications  of,  289 
cases  of,  517,  524,  527 

neglect  of,  280 

resulting  from  constitutional  disease, 
285,  291 

resulting  from  use  of  nasal  douche, 
285 

statistics  of,  279 

symptoms  of,  280 

treatment  of,  286 
Middle  ear,  acute  suppuration  of,  307 

causes  of,  309 

consequences  of  neglect  of,  331 
cases  of,  321,  323,  333 

mastoid  complication  of,  oil 
case  of,  502,  509 

pain  in,  307 

phthisis  pulmonalis  complicating,  308 

prognosis  of,  331 

symptoms  of,  308 

termination  of,  311 

treatment,  of  318 
Middle  ear,  anatomy  of,  213 

diseases  of,  278 

physiology  of,  254 
Middle  ear,  chronic  catarrh  of,  343 


738 


INDEX   OF   SUBJECTS. 


Middle  ear,  chronic  catarrh  of, 

causes  of  aural  hallucinations  in,  316 

objective  symptoms  of,  352 

pathology  of,  374 

subjective  symptoms  of,  344 

treatment  of,  380 
Middle  ear.  chronic  suppuration  of, 

astringents  in,  456,  463 

cases  of,  469^472 

causes  of,  443 

cleansing  of  tympanum  in,  461 

cleansing  with  cotton  in.  454 

confounded  with  inflammation  of  ex- 
ternal auditory  canal,  444 

consequences  of,  473,  496 

danger  to  health  and  life  from,  448, 
473 

dry  treatment  of,  457 

electricity  in,  462 

Eustachian  tube  in,  448 

general  health  in,  468 

granulations  in,  455 

healing  of  membrana  tympani  in,  463 

impaired  hearing  in,  450 

inflation  in,  454,  458 

inspissated  cerumen  in,  445 

inspissated  pus  in,  461 

life  insurance  in,  473 

mastoid  complications  in,  445 
cases  of,  502,  509 

method  of  cleansing,  453 

objections  to  use  of  syringe  in,  452 

pain  in,  446 

perforation  of  membrana  tvmpani  in, 
442 

phthisis  pulmonalis  complicating,  464 

polypi  in,  474 

prognosis  of,  468  . 

removal  of  ossicles  in,  464 

results  of  long-standing,  446 
of  neglect,  448 

skin-grafting  in,  459 

statistics  of,  444 

supposed     danger    of  stopping    dis- 
charge, 19,  449 

symptoms  of,  445 

syringing,  451 

treatment  of,  451 

warm  solutions  in,  457 

warm  water  in,  451 

"Middle  ear,  croupous  inflammation  of,  317 
Middle  ear,  diphtheritic  inflammation  of, 

303 
JVIiddle  ear,  hemorrhagic  inflammation  of, 

297 
Middle  ear,  hypertrophic  inflammation  of, 

376 

Middle  ear,  neuralgia  of,  583 
Middle  ear,  non-Buppurative  inflammation 
of,  339 

changes  of  membrani  tympani  in,  364 

differential  diagnosis  of,  352 


Middle  ear,  non  suppurative  inflammation 
of, 

duration  before  advice  is  sought,  341 

operations  for,  414 

paracentesis  in  cases  of,  416 

pathology  of,  375 

prognosis  of,  441 

statistics  of,  341 

supposed  nervous  deafness,  341 

symptoms  of,  344,  351 

treatment  of,  380 

Middle  ear,  proliferous  inflammation  of, 
343 

causes  of,  376 

constitutional  remedies  in,  381 

pathology  of,  375 

prognosis  of,  411 

symptoms  of,  351 

treatment  of.  381 
Middle  ear,  physiology  of,  254 
Middle  ear,  sympathetic  inflammation  of, 

267 
Middle  ear,  sub- acute  inflammation  of,  293 

cases  of,  296 

pathology  of,  295 

symptoms  of,  293 

treatment  of,  294 

Middle  ear,  serous  inflammation  of,  337 
Middle  ear,  statistics  of  occurrence  of  dis- 
ease of,  213 

Mineral  acids  in  chronic  suppurative  in- 
flammation, 458 
Mixed  cases,  352 
Modiolus,  7 
Mouth-breathing,  396 
Mucous  polypi,  475 
Mumps,  cause  of  disease  of  ear,  655 
Muscida  lucilia,  182 

sarcophaga,  182 
Muscles  of  auricle,  83 

of  tympanum,  256 
Musculus  incisurse  majoris  auriculae  San- 

torini,  85 
Myringa,  7 
Myringitis,  260 
Myringodectomy,  427 
Myringomykosis,  144 
Myringoplasty,  460 
Myxomata,  475 

\TARES  in  chronic  catarrh  of  middle  ear, 
1>         372 

proliferous  inflammation,  351 
Nasal  catarrh,  case  of  acute  suppuration 

from,  335 
Nasal  douche,  309,  384 

case    of    inflammation   and    pyaemia 

from,  385 
Nasal  pad,  76 
Nasal  speculum,  68 
Naso-pharyngeal  inflammation,  377 
Nausea  from  syringing,  452 


INDEX   OF   SUBJECTS. 


739 


Nebulizer,  Eustachian,  403 

naso-pharyngeal,  392 
Necrosis  of, 

auditory  canal,  156 

labyrinth,  548 

temporal  bone,  505,  545 
case  of,  553 
case  of,  with   membrana   tympani 

intact,  547 
Nervousness,  614 
Neuralgia  of  ear,  583 

cases  of,  586 

Neuroma  of  internal  auditory  canal,  680 
Nerve,  auditory,  inflammation  of,  652 
Nerve  deafness,  54,  612 

diagnosis  of,  614 
Nitrate  of  silver,  393,  456,  481 
Nitric  acid,  481 
Noise,  hearing  better  in,  355,  363,  625 

OBLIQUUS  auricula?,  85 
Ophthalmoscope  in  aural  disease,  573 
Ossicula  auditus,  232 

adhesions  of,  375,  474 

coverings  of,  9 

dimensions  of,  233 

discovery  of,  5 

functions  of,  256 

ligaments  of,  233 

loss  of,  case  of,  333 

mechanism  of  articulation  of,  234 

necrosis  of,  333,  546 

periosteum  of,  at  birth,  223 

removal  of,  464 

Osteo-sarcoma  of  tympanum,  479 
Otalgia,  583 
Othsematomata,  107. 

cases  of,  109 

forms  of,  107,  112 

pathology  of,  109 

treatment  of,  113 
Otic  ganglion,  237 
Otology, 

definition  of,  2 

hindrance  to  advance  of,  38 

progress  of,  1 
Otoconia,  599 
Otolith,  599 

Otomyces  purpurus,  146 
Otorrhoea,  443,  446 
Otoscope, 

binocular,  64 

Blake's  operating,  65 

interference,  58 

Siegle's,  78,  368 

Von  Troltsch's,  61 

PAIN  and  sensitiveness  to  sound,  628 
Panotitis,  306,  309 

Paracentesis  of  membrana  tympani,  288 
death  following,  422 
first  performed,  416 


Paracentesis  of  membrana  tympani, 

for  accumulations,  424 

history  of,  415 

indications  for,  435 

instruments  for,  435 

statistics  of,  424 

with  galvano-cautery,  427 
Paracusis  Willisiana,  22,  357 
Paralysis  of  seventh  nerve,  571 

case  of,  from  acute  inflammation  of 

ear,  323 
Parasitic  inflammation  of  ear,  143 

cases  of,  144,  151 
Paretic  deafness,  439 
Parotitis,  655,  716 

cases  of,  656 
Pathology, 

of  labyrmthian  disease,  679 

of  non-suppurative  inflammation,  374 
Pencillimn,  150 
Pencillium  glaucum,  146 
Perilymph,  591 
Periostitis,  mastoid,  496 
Pharmaco-koniautron,  429 
Pharyngitis  granulosa,  369 
Pharynx, 

astringents  in  treating  the,  393 

examination  of,  65 

gargles  in  treating  the,  392 

Gruber's  method  of  cleansing,  391 

injection  of,  383 

in  acute  catarrh  of  middle  ear,  280 

in  acute  suppuration  of  middle  ear, 
320 

in  chronic  catarrh  of  middle  ear.  350 

in  chronic  suppuration  of  middle  ear, 
448 

in  non-suppurative  inflammation   of 
middle  ear,  369 

in  proliferous  inflammation,  331 

treatment  of,  383 
Phlebitis  in  mastoid  disease,  499 
Phlegmosa  alba  dolens,  499 
Phlegmonous  inflammation  of  neck,  49'.) 
Piano  test  for  hearing,  58 
Plaster  of  Paris  in  suppurative  inflamma- 
tion of  middle  ear,  455 
Pneumonia,   case  of   aural  disease   from, 

655 
Polypi, 

cases  of,  477,  484 

cause  of,  477 

classification  of,  475 

in  external  auditory  canal,  125 
tympanic  cavity,  474 

nature  of,  475 

on  exostoses,  489 

origin  of,  475 
of  name,  474 

puncture  of,  482 

removal  of,  with  curette,  482 
with  caustics,  455 


740 


INDEX   OF   SUBJECTS. 


Polypi, 

removal  of,  with  forceps,  481 

with  snare,  480 
resume  of  our  knowledge  of,  485 

treatment  of,  480-484 
Post  nasal  syringe,  25,  383 
Poultices  in 

acute  catarrh  of  middle  ear,  288 

mastoid  periostitis,  501 
Powder-blower,  457 
Pregnancy,  cause  of  aural  disease,  378 
Presbykousis,  620,  719 
Probing,  danger  of,  158 
Processus  lenticularis,  233 

folianus,  233 

gracilis,  233 
Proliferous  inflammation  of   middle  ear, 

351 

Promontory,  230 

Pulsation  in  tympanic  cavity,  447 
Pyaemia,  310,  457,  524,  566 

cases  of,  385,  567 
Pyramid,  230 
Pyramis  vestibuli,  593 

QUININE,  effects  of.  379,  641 
case  of  aural  disease  from,  171,  642 

"DECESSUS  cochlearis,  593 
ft     Record  of  patients,  44 
Reflex  symptoms,  204 
Reissner's  membrane,  602 
Register  of  hearing  power,  48 
Resection  of  tympanic  ring,  201 
Resorcin,  456 

Restilorm  bodies,  section  of,  111 
Retrahens  auriculam,  83 
Rhinoscopy,  66,  371 
Rivinian  foramen,  9,  216 

segment  of  membrana  tympani,  216 

SACCULE,  600 
Salpingo-pharyngeus  muscle,  251 
Santorini  incisurae,  85 
Sarcoma  of  auricle,  117 

internal  auditory  canal,  680 
Scala  tympani,  597 

vestibuli,  597 

Scarlet  fever,  cause  of  aural  disease,  285, 
333,  654.  709 

cases  of,  333,  655 
Sciatic  nerve,  effect  on  auricle  of  irritation 

of,  111 
Sea  bathing,  cause  of  acute  suppuration, 

310 
Semi-circular  canals, 

anatomy  of,  593 

bony,  594 

disease  of,  676 
case  of,  678 

first  described,  5 
Sensory  centre  of  auditory  nerve,  610 


Sentences,  test  for  hearing,  46 

Serous  inflammation  of  middle  ear,  337 

Shrapnell's  membrane,  11,  216 

Siegle's  otoscope,  78,  368 

Sinus  subciformis,  593 

Skin-grafting  for  loss  of  membrana  tym- 

pani,  459 

Small-pox,  cause  of  aural  disease,  714 
Snare, 

Blake's,  480 

Wilde's,  480 
Sonofactors,  48 
Sound  of  one's  voice  in  aural  disease,  284 

determination  of  direction  of.  611 
Speaking-trumpets,  719 

tubes,  16,  719 
Speculum, 

anterior  nasal,  68 

bivalvular,  60 

Elsberg's,  69 

first  used,  18 

for  ear.  60 

hinge,  66 

pharyngeal,  66 

Siegle's.  78,  368 

Spheno-staphylinus  muscle,  246,  249 
Spina  seu  crista  helicis,  81 
Stapedius  muscle,  7,  235,  257 
Stapes,  6,  232 

anchylosis  of,  24,  375,  474 
Steam,  use  of,  398-400 
Stemphyllium,  147 
Sterility,  ancient  idea  of  cause  of,  22 
Styptic  cotton,  484 
Sulcus  spiralis,  601 
Sulcus  pro  membrana  tympani,  92 
Sulphate  of  zinc,  459 
Surf-bathing,  protection  of  ears  in,  284 
Supposed  foreign  body  in  ear,  200-202 
Suppuration  of  middle  ear,  acute,  307 

chronic,  441 
Syringe,  133,  451 

first  used,  20 

method  of  using,  134 
Syringing, 

for  foreign  bodies,  187,  195 

furuncle,  138 

inflammation    of    external    auditory 
canal,  135 

inspissated  cerumen,  166 

naso-pharynx,  383 

parasitic  inflammation.  150 

pharynx,  Gruber's  method,  391 

suppuration  of  middle  ear,  acute,  319 

chronic,  451 
Syphilis  of  external  ear,  154 

internal  ear,  630 

middle  ear,  378 

TEETH  in  relation  to  aural  disease.  584 
Temporal  bone,  caries  of,  24,  545 
Tensor  palati  muscle,  paralysis  of,  439 


INDEX   OF   SUBJECTS. 


741 


Tensor  tympani, 

action  of,  12 

attachment  of,  8,  235 

discovery  of,  8 

function  of,  256 

tenotoiny,  of  427 
Termination  of  diphtheritic  inflammation 

of  the  middle  ear,  305 
Tests  of  hearing  power.  45 
Therapeutics,  progress  of,  13 
Tinnitus  auriuin,  281 

cause  of,  349 

different  sounds  of,  348 

effect  on  the  mind,  346 

objective,  349 

Tones,  deafness  for  certain,  624 
Tongue  specula,  66 

Tonsils  in  non-suppurative  inflammation 
of  middle  ear,.369 

removal  of,  395 
Toynbee's  disk,  465 
Tractus  spiralis  foraminosus,  606 
Tragicus  muscle,  84 
Tragus,  4,  82 
Trausversus  auriculae,  85 
Traumatism,  cause  of  suppurative  inflam- 
mation of  the  middle  ear,  310 
Trephine,  Wilson's,  543 
Trephining  of  mastoid,  506 

history  of,  536 
Triangular  spot  of  light.  218 
Trichothecium  roseum,  146,  148 
Tubulus  hirsutus,  1 78 
Tumors  of  auricle,  103 

of  brain.  673 

of  membrana  tympani,  302 
Tuning-fork, 

discovery  of,  use  of,  19 

duration  of  vibration,  55 

effect  on  membrana  tympani,  13 

explanation  of,  56 

history  of  its  use.  52 

in  disease  of  middle  ear,  54,  352 

in  disease  of  internal  ear,  54,  58,  615 

in  disease  of  labyrinth,  621 

method  of  using,  52-57 

test  for  hearing  power,  45,  51,  621 
Turkish  bath,  382 


Tympanic  syringe,  Hartmaun's,  463 
Tympanum, 

a  series  of  anatomical  parts,  447 

agents  used  through  catheter,  403 

blood-vessels  of,  236 

catheter  for,  70,  401 

definition  and  description  of,  227 

injecting  with  fluids,  434 

lining  membrane  of,  236 

measurements  of,  228 

nerves  of,  237 

objects  for  examination.  228 

openings  in  walls  of,  229 

relations  of,  231,  450 

roof  of,  230 

syringing  of,  through  Eustachian  tube. 
461 

syringing,  452 

UMBO,  219,  224 
Urine,  ancient  instillation  of,  23 
Utricle,  598 

TTALSALVIAN  experiment,  24,  77,  366 
Y     Vapors  in  non  suppurative  inflamma- 
tion, 398 

Vernix  caseosa.  94 
Vertigo,  345,  452 
Vestibule. 

anatomy  of,  591 

physiology,  607 
Vestibular  nerve,  606 
Vomiting,  effect  of,  268 

WAKM  oil,  use  of,  13 
Warm  water,  instillations,  14,  282, 

451 

solutions,  457 

Watch  as  a  test  of  hearing,  47,  50 
Whooping-cough,  715 

case  of  acute  suppuration  of  middle 

ear  from,  334 
Wilde's  incision,  499 
Worms  in  the  ear,  15,  17,  23,  181 

ZOXA  denticulata,  13 
pectinata,  13,  602 


Date  Due 


01979 


II 


CAT.    NO.    23    233  PRINTED    IN    U.S.A. 


W200 
R78lp 

1891 
Roosa.  Daniel  B        S 

A  practical  treatise  on  the  diseases 
of  the  ear 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


